Healthcare Provider Details

I. General information

NPI: 1407900434
Provider Name (Legal Business Name): BLKC, INC. (D/B/A PREMIER COMPOUNDING PHARMACY)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 VILLAGE DR
SAINT JOSEPH MO
64506-2459
US

IV. Provider business mailing address

1427 VILLAGE DR
SAINT JOSEPH MO
64506-2459
US

V. Phone/Fax

Practice location:
  • Phone: 816-279-6700
  • Fax: 816-279-5603
Mailing address:
  • Phone: 816-279-6700
  • Fax: 816-279-5603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number006462
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2013022132
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number041133
License Number StateMO

VIII. Authorized Official

Name: WILLIAM A LIPIRA
Title or Position: PRESIDENT/PHARMACIST
Credential:
Phone: 816-279-6700