Healthcare Provider Details

I. General information

NPI: 1003603903
Provider Name (Legal Business Name): NORTHERN LIGHTS COMPOUNDING INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 S STEPHENSON AVE STE 2
IRON MOUNTAIN MI
49801-4038
US

IV. Provider business mailing address

PO BOX 189
IRON MOUNTAIN MI
49801-0189
US

V. Phone/Fax

Practice location:
  • Phone: 906-376-0910
  • Fax:
Mailing address:
  • Phone: 906-774-1044
  • Fax: 906-774-6833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JORDAN MARCHETTI
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 906-376-0910