1891169090 NPI number — ISLAND COMPOUNDING PHARMACY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891169090 NPI number — ISLAND COMPOUNDING PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND COMPOUNDING PHARMACY 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:
6
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:
1891169090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 MATHEWS DR STE 215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILTON HEAD ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29926-3731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-686-3040
Provider Business Mailing Address Fax Number:
843-686-3035

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 MATHEWS DR STE 215
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILTON HEAD ISLAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29926-3731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-686-3040
Provider Business Practice Location Address Fax Number:
843-686-3035
Provider Enumeration Date:
11/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FRY
Authorized Official First Name:
WILHEMINA
Authorized Official Middle Name:
SMITH
Authorized Official Title or Position:
OWNER/SOLE MEMBER
Authorized Official Telephone Number:
843-686-3040

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  16203 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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