Healthcare Provider Details

I. General information

NPI: 1801926878
Provider Name (Legal Business Name): PAVILION COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3193 HOWELL MILL RD NW STE 122A
ATLANTA GA
30327-2119
US

IV. Provider business mailing address

3193 HOWELL MILL RD NW STE 122A
ATLANTA GA
30327-2119
US

V. Phone/Fax

Practice location:
  • Phone: 404-350-5780
  • Fax: 404-350-5640
Mailing address:
  • Phone: 404-350-5780
  • Fax: 404-350-5640

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 NumberPHRE006901
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BRAD CHERSON
Title or Position: OWNER/MANAGER
Credential: RPH
Phone: 404-350-5780