Provider Demographics
NPI:1104944289
Name:PHARMACY COMPOUNDING SPECIALTIES
Entity type:Organization
Organization Name:PHARMACY COMPOUNDING SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STORE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:214-327-8200
Mailing Address - Street 1:8061 WALNUT HILL LN
Mailing Address - Street 2:SUITE 924
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8061 WALNUT HILL LN
Practice Address - Street 2:SUITE 924
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4331
Practice Address - Country:US
Practice Address - Phone:214-327-8200
Practice Address - Fax:214-327-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336S0011X
TX215103336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4522428OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4522428OtherOTHER ID NUMBER