Provider Demographics
NPI:1689714552
Name:PROFESSIONAL COMPOUNDING OF ROSWELL INC
Entity Type:Organization
Organization Name:PROFESSIONAL COMPOUNDING OF ROSWELL INC
Other - Org Name:PROFESSIONAL COMPOUNDING OF ROSWELL INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-622-6578
Mailing Address - Street 1:700 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3956
Mailing Address - Country:US
Mailing Address - Phone:575-622-6578
Mailing Address - Fax:575-623-3801
Practice Address - Street 1:700 N UNION AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3956
Practice Address - Country:US
Practice Address - Phone:575-622-6578
Practice Address - Fax:575-623-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000023053336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2058933OtherPK
3210969OtherOTHER ID NUMBER-COMMERCIAL NUMBER