Provider Demographics
NPI:1780333229
Name:AVITA DRUGS LLC
Entity type:Organization
Organization Name:AVITA DRUGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR REGULATORY COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-592-2010
Mailing Address - Street 1:10604 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 CAILLOUETT PL STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-7807
Practice Address - Country:US
Practice Address - Phone:337-443-7470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVITA DRUGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPHY.008441-RCOtherBOARD OF PHARMACY