Provider Demographics
NPI:1871620526
Name:AVALON PHARMACY, INC
Entity type:Organization
Organization Name:AVALON PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:256-314-1001
Mailing Address - Street 1:2400 AVALON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-3164
Mailing Address - Country:US
Mailing Address - Phone:256-314-1001
Mailing Address - Fax:256-314-1002
Practice Address - Street 1:2400 AVALON AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-3164
Practice Address - Country:US
Practice Address - Phone:256-314-1001
Practice Address - Fax:256-314-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL110779332B00000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009703940Medicaid
AL100002842Medicaid
AL009703940Medicaid