Provider Demographics
NPI:1801926878
Name:PAVILION COMPOUNDING PHARMACY LLC
Entity type:Organization
Organization Name:PAVILION COMPOUNDING PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:404-350-5780
Mailing Address - Street 1:3193 HOWELL MILL RD NW
Mailing Address - Street 2:STE 122A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2119
Mailing Address - Country:US
Mailing Address - Phone:404-350-5780
Mailing Address - Fax:404-350-5640
Practice Address - Street 1:3193 HOWELL MILL RD NW
Practice Address - Street 2:STE 122A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2119
Practice Address - Country:US
Practice Address - Phone:404-350-5780
Practice Address - Fax:404-350-5640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X, 3336S0011X
GAPHRE0069013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2015906OtherPK