Provider Demographics
NPI:1205377173
Name:PREMIER COMPOUNDING PHARMACY, INC.
Entity Type:Organization
Organization Name:PREMIER COMPOUNDING PHARMACY, INC.
Other - Org Name:PREMIER PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, OWNER
Authorized Official - Phone:888-507-8621
Mailing Address - Street 1:2000 PGA BLVD.
Mailing Address - Street 2:SUITE 5507
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33408
Mailing Address - Country:US
Mailing Address - Phone:888-507-8621
Mailing Address - Fax:
Practice Address - Street 1:2000 PGA BLVD.
Practice Address - Street 2:SUITE 5507
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33408
Practice Address - Country:US
Practice Address - Phone:888-507-8621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER COMPOUNDING PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH234813336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168181OtherPK