Provider Demographics
NPI:1942548367
Name:AVALON MARKETING INC
Entity Type:Organization
Organization Name:AVALON MARKETING INC
Other - Org Name:AVALON PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CHIGOZIE
Authorized Official - Last Name:MADUKA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-383-0142
Mailing Address - Street 1:12100 ANNAPOLIS ROAD 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 ROAD 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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP058833336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD456105800Medicaid