Provider Demographics
NPI:1669721239
Name:MEDFORD COMPOUNDING & SPECIALTY PHARMACY LLC
Entity type:Organization
Organization Name:MEDFORD COMPOUNDING & SPECIALTY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VPF
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-475-4141
Mailing Address - Street 1:2608 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2551
Mailing Address - Country:US
Mailing Address - Phone:631-475-4141
Mailing Address - Fax:631-475-4911
Practice Address - Street 1:2612 ROUTE 112
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2522
Practice Address - Country:US
Practice Address - Phone:631-693-1403
Practice Address - Fax:631-654-1508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
NY0313873336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136843OtherPK