Healthcare Provider Details

I. General information

NPI: 1922116193
Provider Name (Legal Business Name): RAINSVILLE COMPOUNDING PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MAIN STREET
RAINSVILLE AL
35986
US

IV. Provider business mailing address

PO BOX 1370 515 MAIN STREET
RAINSVILLE AL
35986-1370
US

V. Phone/Fax

Practice location:
  • Phone: 256-638-2255
  • Fax:
Mailing address:
  • Phone: 256-638-2255
  • Fax: 256-638-2257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0131526
License Number StateAL

VIII. Authorized Official

Name: WADE PHILLIPS
Title or Position: SUPERVISING PHARMACIST
Credential: PHARMD
Phone: 256-638-2255