Organization
AVITA DRUGS, LLC
Active
Other names
Avita Pharmacy 1075
Organization subpart
No
Provider details
NPI number
Authorized official
CARL CODY COLQUITT (CHIEF FINANCIAL OFFICER)
(469) 592-2011
Entity
Organization
Contact information
Practice address
315 N SAN SABA, SUITE 110, SAN ANTONIO, TX 78207
(210) 212-7455
(210) 212-6643
Mailing address
5700 GRANITE PARKWAY, SUITE 425, PLANO, TX 75024-6648
(469) 592-2011
(210) 569-6464
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
28483
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
148764
—
TX
01
—
2139698
PK
—
Enumeration date
04/17/2013
Last updated
04/17/2023
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