NPIMap

Organization Active NPI

Pharmblue LLC

Doing business as Avita

  • Community/Retail Pharmacy
  • Philadelphia, PA
National Provider Identifier
1386984771
Registry record updated Feb 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
PHAO1275 Issued in AK
Legal business name
PHARMBLUE LLC
Doing business as
Avita
Avita Pharmacy 1059
PharmBlue LLC
Practice address
1226 Chestnut St
Philadelphia, PA 19107-4849
Phone
(855) 779-4720
Fax
(558) 779-4721
NPI assigned
Feb 21, 2013
Last updated
Feb 20, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 20, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Carl Cody Colquitt
Title
Chief Financial Officer
Phone
(469) 850-6930

Specialties & licenses 15

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X A9-0001259 DE
Community/Retail Pharmacy 3336C0003X 22-13036 KS
Community/Retail Pharmacy 3336C0003X NRX0000260 DC
Community/Retail Pharmacy 3336C0003X OSP.0006224 CO
Community/Retail Pharmacy 3336C0003X PMP854 HI
Community/Retail Pharmacy 3336C0003X PA1671 KY
Community/Retail Pharmacy 3336C0003X 22299MS ID
Community/Retail Pharmacy 3336C0003X PCN.0002541 CT
Community/Retail Pharmacy 3336C0003X PH27097 FL
Community/Retail Pharmacy 3336C0003X 64001499A IN
Community/Retail Pharmacy 3336C0003X 4214 IA
Community/Retail Pharmacy 3336C0003X 054.018350 IL
Community/Retail Pharmacy 3336C0003X PHNR000016 GA
Community/Retail Pharmacy 3336C0003X 1495 CA
Community/Retail Pharmacy 3336C0003X PHAO1275 AK Primary

Addresses

Primary practice location

1226 Chestnut St
Philadelphia, PA 19107-4849

Mailing address

10604 Coursey Blvd
Baton Rouge, LA 70816-4015
Phone (469) 592-2011

Other identifiers 15

IdentifierTypeStateIssuer
1386984771MedicaidWA
1386984771MedicaidMN
102811091 0001MedicaidPA
1386984771MedicaidVA
1386984771MedicaidMT
7P2344MedicaidSC
82828501MedicaidDC
2139860OtherPK
500689502MedicaidOR
10026562700MedicaidNE
152103MedicaidOH
48076554MedicaidNM
1386984771MedicaidTN
3096207MedicaidNH
70409100MedicaidMD

Other names 3

  • Avita Doing business as
  • Avita Pharmacy 1059 Doing business as
  • PharmBlue LLC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130531000191 PA Part B Supplier - Pharmacy 3678711769 Practice locations: Philadelphia, PA

National Provider Directory

National Provider Directory
Tax ID family
Avita2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

10604 Coursey Blvd
Ste 425
Baton Rouge, LA 70816

1226 Chestnut St
Philadelphia, PA 19107
Phone (724) 779-4720

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1361404800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1740009600000",
    "number": "1386984771",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10604 COURSEY BLVD",
            "city": "BATON ROUGE",
            "state": "LA",
            "postal_code": "708164015",
            "telephone_number": "469-592-2011"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1226 CHESTNUT ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191074849",
            "telephone_number": "855-779-4720",
            "fax_number": "558-779-4721"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHARMBLUE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-21",
        "last_updated": "2025-02-20",
        "certification_date": "2025-02-20",
        "status": "A",
        "authorized_official_last_name": "COLQUITT",
        "authorized_official_first_name": "CARL",
        "authorized_official_middle_name": "CODY",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "469-850-6930"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "DE",
            "license": "A9-0001259",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "KS",
            "license": "22-13036",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "DC",
            "license": "NRX0000260",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "CO",
            "license": "OSP.0006224",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "HI",
            "license": "PMP854",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "KY",
            "license": "PA1671",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "ID",
            "license": "22299MS",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "CT",
            "license": "PCN.0002541",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "FL",
            "license": "PH27097",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IN",
            "license": "64001499A",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IA",
            "license": "4214",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IL",
            "license": "054.018350",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "GA",
            "license": "PHNR000016",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "CA",
            "license": "1495",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "AK",
            "license": "PHAO1275",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1386984771",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1386984771",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "102811091 0001",
            "state": "PA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1386984771",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1386984771",
            "state": "MT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7P2344",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "82828501",
            "state": "DC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2139860",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500689502",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10026562700",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "152103",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "48076554",
            "state": "NM"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1386984771",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3096207",
            "state": "NH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "70409100",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Avita",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Avita",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Avita Pharmacy 1059",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PharmBlue LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 20, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.