Provider Demographics
NPI:1609032259
Name:PREMIER COMPOUNDING PHARMACY INC
Entity Type:Organization
Organization Name:PREMIER COMPOUNDING PHARMACY INC
Other - Org Name:PREMIER CUSTOM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-691-4991
Mailing Address - Street 1:2000 PGA BLVD
Mailing Address - Street 2:STE 5507
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33408-2722
Mailing Address - Country:US
Mailing Address - Phone:561-691-4991
Mailing Address - Fax:561-691-4998
Practice Address - Street 1:2000 PGA BLVD STE 5507
Practice Address - Street 2:STE 5507
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33408-2726
Practice Address - Country:US
Practice Address - Phone:561-691-4991
Practice Address - Fax:561-691-4998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336S0011X
FLPH234813336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2116428OtherPK
FL002422000Medicaid