Healthcare Provider Details

I. General information

NPI: 1770010068
Provider Name (Legal Business Name): ONESOURCE COMPOUNDING PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 WHISPERING PINES DR STE 105
SCOTTS VALLEY CA
95066
US

IV. Provider business mailing address

104 WHISPERING PINES DR STE 105
SCOTTS VALLEY CA
95066-4799
US

V. Phone/Fax

Practice location:
  • Phone: 831-535-6864
  • Fax:
Mailing address:
  • Phone: 831-535-6864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHY 55294
License Number StateCA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MRS. SESYLIA ASTOR
Title or Position: PHARMACIST
Credential: RPH
Phone: 831-345-6404