Provider Demographics
NPI:1154598266
Name:AVITA DRUGS LLC
Entity type:Organization
Organization Name:AVITA DRUGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-592-2011
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:225-236-1540
Mailing Address - Fax:225-663-2158
Practice Address - Street 1:6100 CORPORATE BLVD STE 250
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-2723
Practice Address - Country:US
Practice Address - Phone:225-924-1930
Practice Address - Fax:225-924-2620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MI53010113383336L0003X
FL269743336L0003X
IA46553336L0003X
AL1142723336L0003X
IN64001792A3336L0003X
MS089293336L0003X
KS22-445263336L0003X
ID41562MS3336L0003X
KYLA20743336L0003X
DEA9-00020753336L0003X
DCNRX00009433336L0003X
MN2649933336L0003X
IL0540199713336L0003X
MO20110407093336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1234893Medicaid
2118871OtherPK