1902526817 NPI number — MOUNTAINSIDE COMPOUNDING LLC

Table of content: (NPI 1902526817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902526817 NPI number — MOUNTAINSIDE COMPOUNDING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAINSIDE COMPOUNDING LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902526817
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 254
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TATE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30177-0254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-454-2323
Provider Business Mailing Address Fax Number:
678-454-2325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4875 HWY 53 E
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
TATE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-454-2323
Provider Business Practice Location Address Fax Number:
678-454-2325
Provider Enumeration Date:
08/31/2022

Additional Information

Authorized Official

Authorized Official Last Name:
TIMMER
Authorized Official First Name:
DAYNA
Authorized Official Middle Name:
MAUREEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-454-2323

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com