Provider Demographics
NPI:1366447005
Name:AVELLA OF PHOENIX II, INC.
Entity Type:Organization
Organization Name:AVELLA OF PHOENIX II, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MUSIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-434-3657
Mailing Address - Street 1:1606 W WHISPERING WIND DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0678
Mailing Address - Country:US
Mailing Address - Phone:623-434-1700
Mailing Address - Fax:623-434-3676
Practice Address - Street 1:5040 N 15TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3329
Practice Address - Country:US
Practice Address - Phone:602-277-3181
Practice Address - Fax:602-277-3418
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APOTHECARY HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-17
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0050913336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0326466OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ630469Medicaid
0326466OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ630469Medicaid