Provider Demographics
NPI:1962779348
Name:POULSBO COMPOUNDING PHARMACY LLC
Entity type:Organization
Organization Name:POULSBO COMPOUNDING PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:KNOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:360-779-2737
Mailing Address - Street 1:PO BOX 2850
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-2850
Mailing Address - Country:US
Mailing Address - Phone:360-779-2737
Mailing Address - Fax:
Practice Address - Street 1:19062 STATE HIGHWAY 305 NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7336
Practice Address - Country:US
Practice Address - Phone:360-779-2737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPHAR.CF.602643953336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy