Provider Demographics
NPI:1013408772
Name:PREMIUM COMPOUNDING INC
Entity Type:Organization
Organization Name:PREMIUM COMPOUNDING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:MARION
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:256-566-8011
Mailing Address - Street 1:3220 HIGHWAY 31 S STE A2
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-1731
Mailing Address - Country:US
Mailing Address - Phone:256-566-8011
Mailing Address - Fax:
Practice Address - Street 1:3220 HIGHWAY 31 S STE A2
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-1731
Practice Address - Country:US
Practice Address - Phone:256-566-8011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1148133336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy