Provider Demographics
NPI:1750592564
Name:AVON MEDICAL PHARMACY
Entity type:Organization
Organization Name:AVON MEDICAL PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-570-0543
Mailing Address - Street 1:ARROW PRESCRIPTION CENTER 11
Mailing Address - Street 2:500 FARMINGTON AVENUE
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105
Mailing Address - Country:US
Mailing Address - Phone:860-524-5304
Mailing Address - Fax:860-524-5836
Practice Address - Street 1:ARROW PRESCRIPTION CENTER 11
Practice Address - Street 2:500 ALBANY AVENUE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06120
Practice Address - Country:US
Practice Address - Phone:860-524-5304
Practice Address - Fax:860-524-5836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1698332B00000X, 332BC3200X, 332BP3500X, 332BX2000X, 333600000X, 3336C0002X, 3336C0003X, 3336C0004X, 3336H0001X, 3336L0003X, 3336M0002X, 3336M0003X, 3336S0011X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Not Answered3336M0002XSuppliersPharmacyMail Order Pharmacy
Not Answered3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5120980001Medicare ID - Type UnspecifiedMEDICARE PROVIDER