Provider Demographics
NPI:1164639431
Name:COMPOUNDED SOLUTIONS IN PHARMACY, LLC
Entity Type:Organization
Organization Name:COMPOUNDED SOLUTIONS IN PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERGE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:203-268-4964
Mailing Address - Street 1:179 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-1107
Mailing Address - Country:US
Mailing Address - Phone:203-268-4964
Mailing Address - Fax:203-268-5492
Practice Address - Street 1:179 MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-1107
Practice Address - Country:US
Practice Address - Phone:203-268-4964
Practice Address - Fax:203-268-5492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4216265Medicaid