Provider Demographics
NPI:1881900074
Name:EMERALD COAST COMPOUNDING PHARMACY
Entity type:Organization
Organization Name:EMERALD COAST COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:FLOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:850-628-6243
Mailing Address - Street 1:19 TOWN CENTER LOOP
Mailing Address - Street 2:UNIT 1-B
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-0700
Mailing Address - Country:US
Mailing Address - Phone:850-628-6243
Mailing Address - Fax:850-622-0580
Practice Address - Street 1:7 TOWN CENTER LOOP
Practice Address - Street 2:UNIT C-15
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-8736
Practice Address - Country:US
Practice Address - Phone:850-628-6243
Practice Address - Fax:850-622-0580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy