Healthcare Provider Details

I. General information

NPI: 1972434819
Provider Name (Legal Business Name): PREMIUM COMPOUNDING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 HIGHWAY 31 S STE A2
DECATUR AL
35603-1731
US

IV. Provider business mailing address

3220 HIGHWAY 31 S STE A2
DECATUR AL
35603-1731
US

V. Phone/Fax

Practice location:
  • Phone: 865-789-0089
  • Fax:
Mailing address:
  • Phone: 865-789-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL BORGHESE
Title or Position: CEO
Credential:
Phone: 865-789-0089