Provider Demographics
NPI:1336467836
Name:AVENUE HEALTHCARE ENTERPRISES INC
Entity Type:Organization
Organization Name:AVENUE HEALTHCARE ENTERPRISES INC
Other - Org Name:AVENUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KAYODE
Authorized Official - Middle Name:EBED-MELECH
Authorized Official - Last Name:BALOGUN
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH, MSC
Authorized Official - Phone:484-816-0344
Mailing Address - Street 1:1111 AVENUE OF THE STATES
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013
Mailing Address - Country:US
Mailing Address - Phone:484-816-0344
Mailing Address - Fax:484-816-0296
Practice Address - Street 1:1111 AVENUE OF THE STATES
Practice Address - Street 2:STORE #2
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:484-816-0344
Practice Address - Fax:484-816-0296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-07
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA333600000XOtherPHARMACY
PA1024548380001Medicaid