Healthcare Provider Details

I. General information

NPI: 1114061132
Provider Name (Legal Business Name): PARK COMPOUNDING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9257 RESEARCH DR
IRVINE CA
92618
US

IV. Provider business mailing address

12264 EL CAMINO REAL STE 350
SAN DIEGO CA
92130-0001
US

V. Phone/Fax

Practice location:
  • Phone: 844-446-6979
  • Fax: 949-551-1950
Mailing address:
  • Phone: 858-704-4040
  • Fax: 858-345-1745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY53360
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ANDREW BOLL
Title or Position: SECRETARY & CFO
Credential:
Phone: 858-704-4040