Provider Demographics
NPI:1851462873
Name:AVITA DRUGS, LLC
Entity Type:Organization
Organization Name:AVITA DRUGS, LLC
Other - Org Name:AVITA PHARMACY 1076
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:CODY
Authorized Official - Last Name:COLQUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-592-2011
Mailing Address - Street 1:5700 GRANITE PARKWAY
Mailing Address - Street 2:SUITE 425
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6648
Mailing Address - Country:US
Mailing Address - Phone:469-592-2011
Mailing Address - Fax:
Practice Address - Street 1:2207 S ZARZAMORA
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-8005
Practice Address - Country:US
Practice Address - Phone:210-223-3863
Practice Address - Fax:210-222-0515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02258333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4504608OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX146631Medicaid