Provider Demographics
NPI:1184716821
Name:AV PHARMA CORP
Entity type:Organization
Organization Name:AV PHARMA CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-597-7733
Mailing Address - Street 1:1703 TERMINO AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2126
Mailing Address - Country:US
Mailing Address - Phone:562-597-7733
Mailing Address - Fax:562-498-1171
Practice Address - Street 1:1703 TERMINO AVE STE 101
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2126
Practice Address - Country:US
Practice Address - Phone:562-597-7733
Practice Address - Fax:562-498-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY501963336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184716821Medicaid
2124665OtherPK
0977380001Medicare NSC