Provider Demographics
NPI:1235318189
Name:MAS PHARMACY AND COMPOUNDING LAB LLC
Entity Type:Organization
Organization Name:MAS PHARMACY AND COMPOUNDING LAB LLC
Other - Org Name:MAS PHARMACY AND COMPOUNDING LAB LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VERA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUMAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-732-9342
Mailing Address - Street 1:705 S GORDON RD SW
Mailing Address - Street 2:STE A
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 S GORDON RD SW
Practice Address - Street 2:STE A
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-5138
Practice Address - Country:US
Practice Address - Phone:770-732-9342
Practice Address - Fax:770-732-9347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GAPHRE0091513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1156466OtherOTHER ID NUMBER