Provider Demographics
NPI:1891165866
Name:COMPOUNDING CORNER PHARMACY, INC.
Entity Type:Organization
Organization Name:COMPOUNDING CORNER PHARMACY, INC.
Other - Org Name:COMPOUNDING CORNER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGUADOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-494-7777
Mailing Address - Street 1:1730 WILLIAMS TRACE BLVD STE K
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-4055
Mailing Address - Country:US
Mailing Address - Phone:281-494-7777
Mailing Address - Fax:281-494-7770
Practice Address - Street 1:1730 WILLIAMS TRACE BLVD STE K
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4055
Practice Address - Country:US
Practice Address - Phone:281-494-7777
Practice Address - Fax:281-494-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336S0011X
TX230383336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154374OtherPK