Provider Demographics
NPI:1083770978
Name:SPECIALTY MEDICINE COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:SPECIALTY MEDICINE COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WALKUP
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-446-2643
Mailing Address - Street 1:350 S LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1814
Mailing Address - Country:US
Mailing Address - Phone:248-446-2643
Mailing Address - Fax:248-486-1906
Practice Address - Street 1:350 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1814
Practice Address - Country:US
Practice Address - Phone:248-446-2643
Practice Address - Fax:248-486-1906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010076103336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N83670Medicare ID - Type Unspecified