Healthcare Provider Details

I. General information

NPI: 1336323567
Provider Name (Legal Business Name): COMPOUNDING SPECIALISTS AT LAKE OCONEE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 COMMERCE DR STE 110
GREENSBORO GA
30642-7444
US

IV. Provider business mailing address

1110 COMMERCE DR STE 110
GREENSBORO GA
30642-7444
US

V. Phone/Fax

Practice location:
  • Phone: 706-923-2933
  • Fax: 706-923-2930
Mailing address:
  • Phone: 706-923-2933
  • Fax: 706-923-2930

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 NumberPHRE009902
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: CAREY VAUGHAN
Title or Position: CEO
Credential: PHARMD
Phone: 706-923-2933