Provider Demographics
NPI:1912488198
Name:MADISON MEDICAL COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:MADISON MEDICAL COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:662-820-4305
Mailing Address - Street 1:111 FOUNTAINS BLVD. BUILDING B STE. A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-707-7545
Mailing Address - Fax:
Practice Address - Street 1:111 FOUNTAINS BLVD. BUILDING B STE. A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-707-7545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171181835P0018X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty
No3336S0011XSuppliersPharmacySpecialty PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM7614642OtherDEA