Provider Demographics
NPI:1043421910
Name:MIDWEST COMPOUNDERS, INC
Entity Type:Organization
Organization Name:MIDWEST COMPOUNDERS, INC
Other - Org Name:MIDWEST COMPOUNDERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:913-498-2121
Mailing Address - Street 1:13330 SANTA FE TRAIL DRIVE
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215
Mailing Address - Country:US
Mailing Address - Phone:913-498-2121
Mailing Address - Fax:913-498-2785
Practice Address - Street 1:13330 SANTA FE TRAIL DRIVE
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215
Practice Address - Country:US
Practice Address - Phone:913-498-2121
Practice Address - Fax:913-498-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-100933336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy