Provider Demographics
NPI:1477718385
Name:COASTAL PHARMACY LABS LLC
Entity Type:Organization
Organization Name:COASTAL PHARMACY LABS LLC
Other - Org Name:COASTAL COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-756-3331
Mailing Address - Street 1:6709 FOREST PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2587
Mailing Address - Country:US
Mailing Address - Phone:912-354-5188
Mailing Address - Fax:912-355-3685
Practice Address - Street 1:6709 FOREST PARK DR STE A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2587
Practice Address - Country:US
Practice Address - Phone:912-354-5188
Practice Address - Fax:912-355-3685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0096343336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141985OtherPK