Healthcare Provider Details

I. General information

NPI: 1164639431
Provider Name (Legal Business Name): COMPOUNDED SOLUTIONS IN PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 MAIN ST
MONROE CT
06468-1107
US

IV. Provider business mailing address

179 MAIN ST
MONROE CT
06468-1107
US

V. Phone/Fax

Practice location:
  • Phone: 203-268-4964
  • Fax: 203-268-5492
Mailing address:
  • Phone: 203-268-4964
  • Fax: 203-268-5492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1717
License Number StateCT

VIII. Authorized Official

Name: MICHAEL ROBERGE
Title or Position: PRINCIPAL MEMBER
Credential: RPH
Phone: 203-268-4964