Provider Demographics
NPI:1124428149
Name:COMPOUNDING SPECALTIES OF CONOVER
Entity type:Organization
Organization Name:COMPOUNDING SPECALTIES OF CONOVER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-464-4491
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-0458
Mailing Address - Country:US
Mailing Address - Phone:828-464-4491
Mailing Address - Fax:828-464-4495
Practice Address - Street 1:317 1ST ST E
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-1715
Practice Address - Country:US
Practice Address - Phone:828-464-4491
Practice Address - Fax:828-464-4495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC077043336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2068812OtherPK