Provider Demographics
NPI:1629435565
Name:AVITA DRUGS LLC
Entity Type:Organization
Organization Name:AVITA DRUGS LLC
Other - Org Name:AVITA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF IT & VENDOR MGMT
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:803-254-5884
Mailing Address - Street 1:5551 CORPORATE BLVD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808
Mailing Address - Country:US
Mailing Address - Phone:225-236-1540
Mailing Address - Fax:888-988-5863
Practice Address - Street 1:3308 TULANE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7100
Practice Address - Country:US
Practice Address - Phone:504-309-2557
Practice Address - Fax:504-827-2437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.007212-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157664OtherPK