Provider Demographics
NPI:1003003823
Name:PURE COMPOUNDING
Entity Type:Organization
Organization Name:PURE COMPOUNDING
Other - Org Name:PURE COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-651-7979
Mailing Address - Street 1:3072 DICK POND RD
Mailing Address - Street 2:STE 2
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6954
Mailing Address - Country:US
Mailing Address - Phone:843-293-7979
Mailing Address - Fax:843-293-6499
Practice Address - Street 1:3072 DICK POND RD
Practice Address - Street 2:STE 2
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6954
Practice Address - Country:US
Practice Address - Phone:843-293-7979
Practice Address - Fax:843-293-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC96393336C0004X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093410OtherPK