Provider Demographics
NPI:1952579484
Name:INTRATHECAL COMPOUNDING SPECIALISTS LLC
Entity type:Organization
Organization Name:INTRATHECAL COMPOUNDING SPECIALISTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-237-6077
Mailing Address - Street 1:206 A JACOBS RUN
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:LA
Mailing Address - Zip Code:70583
Mailing Address - Country:US
Mailing Address - Phone:337-237-6077
Mailing Address - Fax:337-237-8841
Practice Address - Street 1:206 A JACOBS RUN
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583
Practice Address - Country:US
Practice Address - Phone:337-237-6077
Practice Address - Fax:337-237-8841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA58563336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2035607OtherPK