Provider Demographics
NPI:1962413500
Name:PAVILION INFUSION THERAPY INC
Entity type:Organization
Organization Name:PAVILION INFUSION THERAPY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DURKIN
Authorized Official - Suffix:
Authorized Official - Credentials:FHFMA
Authorized Official - Phone:904-202-5887
Mailing Address - Street 1:3563 PHILIPS HWY
Mailing Address - Street 2:STE 202
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5663
Mailing Address - Country:US
Mailing Address - Phone:904-202-5730
Mailing Address - Fax:904-398-2225
Practice Address - Street 1:3563 PHILIPS HWY
Practice Address - Street 2:STE 202
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5663
Practice Address - Country:US
Practice Address - Phone:904-202-5730
Practice Address - Fax:904-398-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
FLPH138013336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102335700Medicaid
2011769OtherPK
1197040001Medicare NSC