1366761538 NPI number — COMPOUNDING SPECIALISTS OF THE SOUTHWEST, INC

Table of content: (NPI 1366761538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366761538 NPI number — COMPOUNDING SPECIALISTS OF THE SOUTHWEST, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPOUNDING SPECIALISTS OF THE SOUTHWEST, INC
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:
1366761538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2140 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88001-1129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-524-2863
Provider Business Mailing Address Fax Number:
575-525-3192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2140 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88001-1129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-524-2863
Provider Business Practice Location Address Fax Number:
575-525-3192
Provider Enumeration Date:
05/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WALLIS
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
575-524-2863

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  PH00003193 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PH0003193 . This is a "RETAIL PHARMACY" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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