Provider Demographics
NPI:1508877002
Name:SAN DIEGO COMPOUNDING PHARMACY A PROF CORP
Entity Type:Organization
Organization Name:SAN DIEGO COMPOUNDING PHARMACY A PROF CORP
Other - Org Name:SAN DIEGO COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-277-8884
Mailing Address - Street 1:5395 RUFFIN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1338
Mailing Address - Country:US
Mailing Address - Phone:858-277-8884
Mailing Address - Fax:858-277-8889
Practice Address - Street 1:5395 RUFFIN RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1338
Practice Address - Country:US
Practice Address - Phone:858-277-8884
Practice Address - Fax:858-277-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY470153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2113433OtherPK