Organization
AVITA DRUGS, LLC
Active
Other names
Avita Pharmacy 1077
Organization subpart
No
Provider details
NPI number
Authorized official
CARL CODY COLQUITT (CHIEF FINANCIAL OFFICER)
(469) 592-2011
Entity
Organization
Contact information
Practice address
2602 N MAIN AVE, SAN ANTONIO, TX 78212-2919
(210) 736-3161
(210) 736-3175
Mailing address
5700 GRANITE PARKWAY, SUITE 425, PLANO, TX 75024-6648
(469) 592-2011
(210) 736-3175
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
01935
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
130275
—
TX
Enumeration date
01/18/2007
Last updated
01/31/2024
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