Provider Demographics
NPI:1194262568
Name:ADVANCED SPECIALTY COMPOUND RX LLC
Entity type:Organization
Organization Name:ADVANCED SPECIALTY COMPOUND RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUSSEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-732-4449
Mailing Address - Street 1:1260 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3407
Mailing Address - Country:US
Mailing Address - Phone:810-732-4449
Mailing Address - Fax:810-732-8188
Practice Address - Street 1:1260 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3407
Practice Address - Country:US
Practice Address - Phone:810-732-4449
Practice Address - Fax:810-732-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010110223336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167410OtherPK