Provider Demographics
NPI:1710157342
Name:INNOVATION COMPOUNDING PHARMACY, LLC
Entity Type:Organization
Organization Name:INNOVATION COMPOUNDING PHARMACY, LLC
Other - Org Name:INNOVATION COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRUMAN
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:BELL
Authorized Official - Suffix:III
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:404-626-1614
Mailing Address - Street 1:6095 PINE MOUNTAIN RD NW
Mailing Address - Street 2:STE 108
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3329
Mailing Address - Country:US
Mailing Address - Phone:770-421-1399
Mailing Address - Fax:
Practice Address - Street 1:6095 PINE MOUNTAIN RD NW
Practice Address - Street 2:STE 108
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3329
Practice Address - Country:US
Practice Address - Phone:770-421-1399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0091493336C0004X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy