Healthcare Provider Details

I. General information

NPI: 1376658740
Provider Name (Legal Business Name): PARK COMPOUNDING PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 N WESTLAKE BLVD STE 100
WESTLAKE VILLAGE CA
91362-3759
US

IV. Provider business mailing address

280 N WESTLAKE BLVD STE 100
WESTLAKE VILLAGE CA
91362-3759
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-8258
  • Fax: 805-497-7548
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY43809
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TONY PARK
Title or Position: VP
Credential: PHRMD
Phone: 805-497-8258