1851636799 NPI number — THE COMPOUNDING SHOPPE &FARMACY,LLC

Table of content: MS. CERISE MARIE BOUCHER ATC (NPI 1003942038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851636799 NPI number — THE COMPOUNDING SHOPPE &FARMACY,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE COMPOUNDING SHOPPE &FARMACY,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:
1851636799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKE FOREST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27587-1649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-569-0500
Provider Business Mailing Address Fax Number:
919-556-4288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAKE FOREST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27587-1649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-569-0500
Provider Business Practice Location Address Fax Number:
919-556-4288
Provider Enumeration Date:
12/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HOLT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
NICHOLAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-215-2307

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  11396 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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