Healthcare Provider Details

I. General information

NPI: 1396925491
Provider Name (Legal Business Name): TIGER TOWN COMPOUNDING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 HOMER RD
COMMERCE GA
30529-1255
US

IV. Provider business mailing address

2025 HOMER RD
COMMERCE GA
30529-1255
US

V. Phone/Fax

Practice location:
  • Phone: 706-335-0099
  • Fax: 706-335-0078
Mailing address:
  • Phone: 706-335-0099
  • Fax: 706-335-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHRE09389
License Number StateGA

VII. Legacy identifiers

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

# 1
Identifier2016757
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: KIM BOST
Title or Position: OWNER
Credential: PHRMD
Phone: 706-335-0099