Healthcare Provider Details

I. General information

NPI: 1710157342
Provider Name (Legal Business Name): INNOVATION COMPOUNDING PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 CHASTAIN MEADOWS PKWY NW SUITE 100
KENNESAW GA
30144
US

IV. Provider business mailing address

3330 CHASTAIN MEADOWS PKWY NW SUITE 100
KENNESAW GA
30144
US

V. Phone/Fax

Practice location:
  • Phone: 800-547-1399
  • Fax: 866-635-2329
Mailing address:
  • Phone: 800-547-1399
  • Fax: 866-635-2329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHRE009149
License Number StateGA

VIII. Authorized Official

Name: BART ZACHARY ANDERSON III
Title or Position: GENERAL MANAGER/PHARMACIST-IN-CHARG
Credential: PHARMD
Phone: 800-547-1399