Healthcare Provider Details

I. General information

NPI: 1194135103
Provider Name (Legal Business Name): ELEMENTS COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 E BASELINE RD SUITE A5-6
MESA AZ
85204-6970
US

IV. Provider business mailing address

2110 E BASELINE RD SUITE A5-6
MESA AZ
85204-6970
US

V. Phone/Fax

Practice location:
  • Phone: 480-625-4750
  • Fax:
Mailing address:
  • Phone: 480-625-4750
  • Fax: 480-625-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberY005900
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY005900
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: PETER PETROV
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 480-625-4750