Provider Demographics
NPI:1679733034
Name:PRESCRIPTION COMPOUNDING SHOPPE
Entity Type:Organization
Organization Name:PRESCRIPTION COMPOUNDING SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-789-2165
Mailing Address - Street 1:327 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:327 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2003
Practice Address - Country:US
Practice Address - Phone:270-465-3784
Practice Address - Fax:270-789-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO65713336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1830721OtherOTHER ID NUMBER