Provider Demographics
NPI:1619481306
Name:LEGACY COMPOUDING INC.
Entity Type:Organization
Organization Name:LEGACY COMPOUDING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:MARION
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:256-353-1123
Mailing Address - Street 1:2422 DANVILLE RD SW STE H
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-4221
Mailing Address - Country:US
Mailing Address - Phone:256-353-1123
Mailing Address - Fax:256-280-3551
Practice Address - Street 1:2422 DANVILLE RD SW STE H
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-4221
Practice Address - Country:US
Practice Address - Phone:256-353-1123
Practice Address - Fax:256-280-3551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL114750332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies