Provider Demographics
NPI:1245012145
Name:LIFESTYLE COMPOUNDING
Entity type:Organization
Organization Name:LIFESTYLE COMPOUNDING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTON
Authorized Official - Middle Name:K
Authorized Official - Last Name:COMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:505-609-5433
Mailing Address - Street 1:3840 COMMONS AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5831
Mailing Address - Country:US
Mailing Address - Phone:505-609-5433
Mailing Address - Fax:505-405-1497
Practice Address - Street 1:3840 COMMONS AVE NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5831
Practice Address - Country:US
Practice Address - Phone:505-609-5433
Practice Address - Fax:505-405-1497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy