Provider Demographics
NPI:1326463936
Name:FOUR CORNERS COMPOUNDING
Entity Type:Organization
Organization Name:FOUR CORNERS COMPOUNDING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-327-4826
Mailing Address - Street 1:2300 E 30TH ST STE B-101
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8991
Mailing Address - Country:US
Mailing Address - Phone:505-327-4826
Mailing Address - Fax:
Practice Address - Street 1:2300 E 30TH ST STE B-101
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8991
Practice Address - Country:US
Practice Address - Phone:505-327-4826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000032393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy