Healthcare Provider Details

I. General information

NPI: 1568802254
Provider Name (Legal Business Name): MIX COMPOUNDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7110 E MCDONALD DR SUITE C-1
SCOTTSDALE AZ
85253-5426
US

IV. Provider business mailing address

7110 E MCDONALD DR SUITE C-1
SCOTTSDALE AZ
85253-5426
US

V. Phone/Fax

Practice location:
  • Phone: 888-229-3775
  • Fax: 602-749-6610
Mailing address:
  • Phone: 888-229-3775
  • Fax: 602-749-6610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberY005618
License Number StateAZ

VIII. Authorized Official

Name: MRS. COURTNEY FORSTER
Title or Position: OWNER
Credential:
Phone: 888-229-3775