Provider Demographics
NPI:1407900434
Name:BLKC, INC. (D/B/A PREMIER COMPOUNDING PHARMACY)
Entity Type:Organization
Organization Name:BLKC, INC. (D/B/A PREMIER COMPOUNDING PHARMACY)
Other - Org Name:PREMIER COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIPIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-279-6700
Mailing Address - Street 1:1427 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2459
Mailing Address - Country:US
Mailing Address - Phone:816-279-6700
Mailing Address - Fax:816-279-5603
Practice Address - Street 1:1427 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2459
Practice Address - Country:US
Practice Address - Phone:816-279-6700
Practice Address - Fax:816-279-5603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041133183500000X
MO006462333600000X
MO2013022132333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty