Provider Demographics
NPI:1710031166
Name:AVITA DRUGS LLC
Entity Type:Organization
Organization Name:AVITA DRUGS LLC
Other - Org Name:AVITA DRUGS LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUBRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-737-4007
Mailing Address - Street 1:6226 JEFFERSON HWY
Mailing Address - Street 2:STE G
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123-5153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6226 JEFFERSON HWY
Practice Address - Street 2:STE G
Practice Address - City:HARAHAN
Practice Address - State:LA
Practice Address - Zip Code:70123-5153
Practice Address - Country:US
Practice Address - Phone:504-737-4007
Practice Address - Fax:504-737-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6048IR3336C0003X
3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1271152Medicaid
MS04874393Medicaid
1931345OtherNCPDP PROVIDER IDENTIFICATION NUMBER