Provider Demographics
NPI:1194736777
Name:APOTEKA COMPOUNDING LLC
Entity type:Organization
Organization Name:APOTEKA COMPOUNDING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KANISKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:480-969-0600
Mailing Address - Street 1:2045 S VINEYARD STE 133
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6893
Mailing Address - Country:US
Mailing Address - Phone:480-969-0600
Mailing Address - Fax:480-969-0712
Practice Address - Street 1:2045 S VINEYARD STE 133
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6893
Practice Address - Country:US
Practice Address - Phone:480-969-0600
Practice Address - Fax:480-969-0712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336M0002X
AZY038243336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ837734Medicaid
1991673OtherPK