Provider Demographics
NPI:1396225694
Name:PROCOMPOUNDING OF THE CAROLINAS 1 INC
Entity Type:Organization
Organization Name:PROCOMPOUNDING OF THE CAROLINAS 1 INC
Other - Org Name:PROCOMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:K
Authorized Official - Last Name:GUINN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:423-975-0597
Mailing Address - Street 1:PO BOX 6075
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-6075
Mailing Address - Country:US
Mailing Address - Phone:423-975-0597
Mailing Address - Fax:
Practice Address - Street 1:77 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-9531
Practice Address - Country:US
Practice Address - Phone:423-975-0597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC137963336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13796OtherNORTH CAROLINA BOARD OF PHARMACY