Provider Demographics
NPI:1841694510
Name:JUPITER COMPOUNDING LLC
Entity type:Organization
Organization Name:JUPITER COMPOUNDING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/AO
Authorized Official - Prefix:
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:DATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-203-8589
Mailing Address - Street 1:155 TONEY PENNA DR
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5746
Mailing Address - Country:US
Mailing Address - Phone:561-203-8589
Mailing Address - Fax:561-406-6816
Practice Address - Street 1:155 TONEY PENNA DR STE 1B
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5746
Practice Address - Country:US
Practice Address - Phone:561-203-8589
Practice Address - Fax:561-203-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X, 3336C0004X, 3336M0002X
FLPH284253336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148293OtherPK