Provider Demographics
NPI:1659761914
Name:PREMIER COMPOUNDING CENTER LLC
Entity Type:Organization
Organization Name:PREMIER COMPOUNDING CENTER LLC
Other - Org Name:PREMIER COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. LAURENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-293-3999
Mailing Address - Street 1:137 CHASE RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-3243
Mailing Address - Country:US
Mailing Address - Phone:401-293-3999
Mailing Address - Fax:401-293-3912
Practice Address - Street 1:137 CHASE RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-3243
Practice Address - Country:US
Practice Address - Phone:401-293-3999
Practice Address - Fax:401-293-3912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
RIPHA005673336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149794OtherPK