Provider Demographics
NPI:1194135103
Name:ELEMENTS COMPOUNDING PHARMACY LLC
Entity type:Organization
Organization Name:ELEMENTS COMPOUNDING PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROV
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:480-625-4750
Mailing Address - Street 1:2110 E BASELINE RD
Mailing Address - Street 2:SUITE A5-6
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6970
Mailing Address - Country:US
Mailing Address - Phone:480-625-4750
Mailing Address - Fax:480-625-3054
Practice Address - Street 1:2110 E BASELINE RD
Practice Address - Street 2:SUITE A5-6
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6970
Practice Address - Country:US
Practice Address - Phone:480-625-4750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0059003336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy