Provider Demographics
NPI: | 1104222629 |
---|---|
Name: | P3 COMPOUNDING PHARMACY LLC |
Entity Type: | Organization |
Organization Name: | P3 COMPOUNDING PHARMACY LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PHARMACIST IN CHARGE |
Authorized Official - Prefix: | |
Authorized Official - First Name: | TRISTA |
Authorized Official - Middle Name: | TANYA |
Authorized Official - Last Name: | TYNER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHARMD |
Authorized Official - Phone: | 843-455-2434 |
Mailing Address - Street 1: | 1140 HAMMOND DR |
Mailing Address - Street 2: | K-220 |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30328-5338 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 404-815-1610 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1140 HAMMOND DR |
Practice Address - Street 2: | K-220 |
Practice Address - City: | ATLANTA |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30328-5338 |
Practice Address - Country: | US |
Practice Address - Phone: | 404-815-1610 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-11-11 |
Last Update Date: | 2014-11-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | RPH027610 | 183500000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 183500000X | Pharmacy Service Providers | Pharmacist | Group - Single Specialty |