Healthcare Provider Details

I. General information

NPI: 1972649598
Provider Name (Legal Business Name): COMPOUND CENTRAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5032 KATELLA AVE.
LOS ALAMITOS CA
90720-2802
US

IV. Provider business mailing address

5032 KATELLA AVE.
LOS ALAMITOS CA
90720-2802
US

V. Phone/Fax

Practice location:
  • Phone: 562-431-2308
  • Fax: 562-431-7124
Mailing address:
  • Phone: 562-431-2308
  • Fax: 562-431-7124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY48388
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. TUAN A NGUYEN
Title or Position: PIC
Credential: RPH
Phone: 562-431-2308