ANOVORX GROUP LLC

Provider Demographics

• NPI: 1619213212
• Name: ANOVORX GROUP LLC
• Entity Type: Organization
• Organization Name: ANOVORX GROUP LLC
• Authorized Official - Title/Position: MANAGING MEMBER/PRESIDENT
• Authorized Official - First Name: JON
• Authorized Official - Last Name: PETERS
• Authorized Official - Phone: 901-201-5484
• Mailing Address - Street 1: 1710 SHELBY OAKS DR N
• Mailing Address - Street 2: SUITE 2
• Mailing Address - City: MEMPHIS
• Mailing Address - State: TN
• Mailing Address - Zip Code: 38134-7403
• Mailing Address - Country: US
• Mailing Address - Phone: 901-201-5470
• Practice Address - Street 1: 1710 SHELBY OAKS DR N
• Practice Address - Street 2: SUITE 1
• Practice Address - City: MEMPHIS
• Practice Address - State: TN
• Practice Address - Zip Code: 38134-7403
• Practice Address - Country: US
• Practice Address - Phone: 901-201-5470
• Practice Address - Fax: 901-201-5465
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2012-12-31
• Last Update Date: 2018-11-28

Provider Licenses

State	License ID	Taxonomies
AK	1314	3336S0011X
DE	A9-0001296	3336S0011X
IN	64001473A	3336S0011X
IL	054.018178	3336S0011X
CO	OSP.0006189	3336S0011X
HI	PMP.833	3336S0011X
AZ	Y005790	3336S0011X
ID	34084MS	3336S0011X
GA	PHNR000415	3336S0011X
IA	4155	3336S0011X
CA	NRP1461	3336S0011X
FL	PH27151	3336S0011X
CT	PCN.0002570	3336S0011X
DC	NRX0000453	3336S0011X
KS	22-13044	3336S0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MS	00320857	Medicaid
NE	100263994-00	Medicaid
CO	92003354	Medicaid
NJ	0422371	Medicaid
MD	079196200	Medicaid
VA	1619213212	Medicaid
IN	201202520A	Medicaid
OR	500671090	Medicaid
VT	1023188	Medicaid
MI	1619213212	Medicaid
MN	1619213212	Medicaid
OK	200528380A	Medicaid
AR	202561407	Medicaid
AL	161796	Medicaid
CT	1619213212	Medicaid
DE	1619213212	Medicaid
ME	1619213212	Medicaid
IA	1619213212	Medicaid
ID	1619213212	Medicaid
UT	1619213212	Medicaid
NC	1619213212	Medicaid
RI	1619213212	Medicaid
KS	201094140A	Medicaid
LA	2202936	Medicaid
KY	7100293170	Medicaid
SC	7T5129	Medicaid
NM	07172541	Medicaid
PA	102865913-0001	Medicaid
ND	1466034	Medicaid
CA	1619213212	Medicaid
	2138743	Other	PK
NH	3095937	Medicaid
GA	003145840A	Medicaid
NV	1619213212	Medicaid
WA	1619213212	Medicaid
MO	1619213212	Medicaid
MT	1619213212	Medicaid
NY	03871258	Medicaid
WY	141805000	Medicaid
TN	1532157	Medicaid
FL	0135576-00	Medicaid
MA	110099495A	Medicaid
WI	1619213212	Medicaid
OH	1619213212	Medicaid
WV	1619213212	Medicaid
TX	1619213212	Medicaid
AZ	897946	Medicaid
MN	1619213212	Medicaid
AR	202561407	Medicaid
	103G872040	Medicare PIN