Healthcare Provider Details

I. General information

NPI: 1376802462
Provider Name (Legal Business Name): ROCK VALLEY COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S PERRYVILLE RD UNIT 109
ROCKFORD IL
61108-4323
US

IV. Provider business mailing address

811 S PERRYVILLE RD UNIT 109
ROCKFORD IL
61108-4323
US

V. Phone/Fax

Practice location:
  • Phone: 779-423-0542
  • Fax: 779-545-2277
Mailing address:
  • Phone: 779-423-0542
  • Fax: 779-545-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054018235
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN M LEHAN
Title or Position: PHARMACIST IN CHARGE
Credential: PHARMD
Phone: 779-423-0542