MEDICARE: CREATIVE COMPOUNDING SOLUTIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	3336C0004X	Compounding Pharmacy	60002334A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2169538	OTHER		PK

General Provider Information

NPI Number	:	1124170014
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE COMPOUNDING SOLUTIONS LLC

Provider Business Mailing Address
First Line	:	2803 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4732
Country	:	US
Telephone Number	:	260-483-3169
Fax Number	:	260-483-3160

Provider Business Practice Location Address
First Line	:	2803 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4732
Country	:	US
Telephone Number	:	260-483-3169
Fax Number	:	260-483-3160

Authorized Official
Title or Position	:	OWNER
Name	:	ANDREW CAMPBELL
Credential	:
Telephone Number	:	260-483-3169

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/19/2018

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