Provider Demographics
NPI:1730471186
Name:AMAVI LLC
Entity Type:Organization
Organization Name:AMAVI LLC
Other - Org Name:HERNDON PHARMACY AND MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIPTESHKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-701-1790
Mailing Address - Street 1:2454 ACORN HOLLOW LN
Mailing Address - Street 2:2454 ACORN HOLLOW LANE
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3405
Mailing Address - Country:US
Mailing Address - Phone:703-579-5137
Mailing Address - Fax:703-481-0127
Practice Address - Street 1:208 ELDEN ST
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4877
Practice Address - Country:US
Practice Address - Phone:703-481-0123
Practice Address - Fax:703-481-0127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201004368333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133233OtherPK