Provider Demographics
NPI:1568600781
Name:MEDICAL CENTER COMPOUNDING LAB
Entity Type:Organization
Organization Name:MEDICAL CENTER COMPOUNDING LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:803-649-1547
Mailing Address - Street 1:410 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 2800
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6810
Mailing Address - Country:US
Mailing Address - Phone:803-649-1547
Mailing Address - Fax:803-648-0120
Practice Address - Street 1:410 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 2400
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6810
Practice Address - Country:US
Practice Address - Phone:803-649-1547
Practice Address - Fax:803-648-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50005156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty