Provider Demographics
NPI:1235537770
Name:ISLAND COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:ISLAND COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LILE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, RPH
Authorized Official - Phone:734-307-7671
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-0419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24201 MERIDIAN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-2134
Practice Address - Country:US
Practice Address - Phone:734-307-7671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010077583336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy