Healthcare Provider Details

I. General information

NPI: 1710377916
Provider Name (Legal Business Name): PRESTIGE COMPOUNDING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 HIGHWAY 78 STE 90
DORA AL
35062-4540
US

IV. Provider business mailing address

PO BOX 1177
DORA AL
35062-1177
US

V. Phone/Fax

Practice location:
  • Phone: 205-313-3560
  • Fax:
Mailing address:
  • Phone:
  • Fax: 888-574-4888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateAL

VIII. Authorized Official

Name: DR. WILLIAM B MYERS
Title or Position: PARTNER
Credential:
Phone: 205-313-3560