Provider Demographics
NPI:1144588468
Name:COMPOUNDIA PHARMACY INC
Entity Type:Organization
Organization Name:COMPOUNDIA PHARMACY INC
Other - Org Name:COMPOUNDIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:VISO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-371-4443
Mailing Address - Street 1:1014 S WESTLAKE BLVD STE 14-291
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-3108
Mailing Address - Country:US
Mailing Address - Phone:855-371-4443
Mailing Address - Fax:
Practice Address - Street 1:766 LAKEFIELD RD STE E
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2661
Practice Address - Country:US
Practice Address - Phone:855-371-4443
Practice Address - Fax:805-371-4375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CA509013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134920OtherPK