Provider Demographics
NPI:1083829170
Name:INNOVATIVE COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:INNOVATIVE COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERPHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RASHIDI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-984-9222
Mailing Address - Street 1:820 WALES DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-5546
Mailing Address - Country:US
Mailing Address - Phone:916-984-9222
Mailing Address - Fax:916-458-8267
Practice Address - Street 1:820 WALES DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-5546
Practice Address - Country:US
Practice Address - Phone:916-984-9222
Practice Address - Fax:916-458-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 484173336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy