Provider Demographics
NPI:1891830550
Name:MODERN COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:MODERN COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PH
Authorized Official - Phone:208-847-0060
Mailing Address - Street 1:762 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1422
Mailing Address - Country:US
Mailing Address - Phone:208-847-0060
Mailing Address - Fax:208-847-0090
Practice Address - Street 1:762 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1422
Practice Address - Country:US
Practice Address - Phone:208-847-0060
Practice Address - Fax:208-847-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1661LS3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy