Provider Demographics
NPI:1790564417
Name:AVALON PROFESSIONAL PHARMACY LLC
Entity Type:Organization
Organization Name:AVALON PROFESSIONAL PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER/PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:MADUKA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-383-0142
Mailing Address - Street 1:12100 ANNAPOLIS RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769
Mailing Address - Country:US
Mailing Address - Phone:301-383-0142
Mailing Address - Fax:301-383-0143
Practice Address - Street 1:12100 ANNAPOLIS RD UNIT 2
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769
Practice Address - Country:US
Practice Address - Phone:301-383-0142
Practice Address - Fax:301-383-0143
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVALON MARKETING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-22
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD456105800Medicaid