Provider Demographics
NPI:1629370481
Name:INNOVATIVE COMPOUNDING
Entity Type:Organization
Organization Name:INNOVATIVE COMPOUNDING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-447-4803
Mailing Address - Street 1:941 CENTER CREST DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:WHITSETT
Mailing Address - State:NC
Mailing Address - Zip Code:27377
Mailing Address - Country:US
Mailing Address - Phone:336-447-4803
Mailing Address - Fax:336-447-4805
Practice Address - Street 1:941 CENTER CREST DR
Practice Address - Street 2:SUITE D
Practice Address - City:WHITSETT
Practice Address - State:NC
Practice Address - Zip Code:27377
Practice Address - Country:US
Practice Address - Phone:336-447-4803
Practice Address - Fax:336-447-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy