Provider Demographics
NPI:1518146547
Name:MIDWESTERN COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:MIDWESTERN COMPOUNDING PHARMACY LLC
Other - Org Name:MIDWESTERN COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:614-573-1557
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064-0126
Mailing Address - Country:US
Mailing Address - Phone:614-733-3784
Mailing Address - Fax:614-300-7558
Practice Address - Street 1:480 S JEFFERSON AVE
Practice Address - Street 2:STE 200
Practice Address - City:PLAIN CITY
Practice Address - State:OH
Practice Address - Zip Code:43064-4137
Practice Address - Country:US
Practice Address - Phone:614-733-3784
Practice Address - Fax:614-721-7996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
OH0216701503336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2081082OtherPK