Provider Demographics
NPI:1508619768
Name:SPECIALTY RX COMPOUNDING & WELLNESS LLC
Entity Type:Organization
Organization Name:SPECIALTY RX COMPOUNDING & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:985-974-6008
Mailing Address - Street 1:1625 HIGHWAY 51 STE J
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-6594
Mailing Address - Country:US
Mailing Address - Phone:985-320-4186
Mailing Address - Fax:
Practice Address - Street 1:1625 HIGHWAY 51 STE J
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-6594
Practice Address - Country:US
Practice Address - Phone:985-320-4186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy