Provider Demographics
NPI:1578785119
Name:PACIFIC COMPOUNDS PHARMACY LLC
Entity Type:Organization
Organization Name:PACIFIC COMPOUNDS PHARMACY LLC
Other - Org Name:PACIFIC COMPOUNDS PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-640-3080
Mailing Address - Street 1:327 SE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4001
Mailing Address - Country:US
Mailing Address - Phone:503-640-3080
Mailing Address - Fax:503-640-3208
Practice Address - Street 1:327 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4001
Practice Address - Country:US
Practice Address - Phone:503-640-3080
Practice Address - Fax:503-640-3208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0001904-CS3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3814402OtherNCPDP PROVIDER IDENTIFICATION NUMBER