Provider Demographics
NPI:1558498634
Name:ABL CUSTOM COMPOUNDING
Entity Type:Organization
Organization Name:ABL CUSTOM COMPOUNDING
Other - Org Name:ABL CUSTOM COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-486-2326
Mailing Address - Street 1:PO BOX 384
Mailing Address - Street 2:
Mailing Address - City:EMPORIUM
Mailing Address - State:PA
Mailing Address - Zip Code:15834-0384
Mailing Address - Country:US
Mailing Address - Phone:814-486-2326
Mailing Address - Fax:814-486-1065
Practice Address - Street 1:34 E 4TH ST
Practice Address - Street 2:
Practice Address - City:EMPORIUM
Practice Address - State:PA
Practice Address - Zip Code:15834-1412
Practice Address - Country:US
Practice Address - Phone:814-486-2326
Practice Address - Fax:814-486-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4817433336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2082235OtherPK