Provider Demographics
NPI:1942830922
Name:CLASSIC COMPOUNDING PHARMACY, LLC
Entity Type:Organization
Organization Name:CLASSIC COMPOUNDING PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:THERIAULT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-351-9010
Mailing Address - Street 1:1171 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-5837
Mailing Address - Country:US
Mailing Address - Phone:207-351-9010
Mailing Address - Fax:207-351-9011
Practice Address - Street 1:1171 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-5837
Practice Address - Country:US
Practice Address - Phone:207-351-9010
Practice Address - Fax:207-351-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy