Healthcare Provider Details

I. General information

NPI: 1073532180
Provider Name (Legal Business Name): ORCHARD HILLS COMPOUNDING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816A W CHESTNUT EXPY
SPRINGFIELD MO
65802-5500
US

IV. Provider business mailing address

3816A W CHESTNUT EXPY
SPRINGFIELD MO
65802-5500
US

V. Phone/Fax

Practice location:
  • Phone: 417-868-8288
  • Fax: 417-868-8248
Mailing address:
  • Phone: 417-868-8288
  • Fax: 417-868-8248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2004012799
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier606157600
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MR. JEFFREY J GOETZINGER
Title or Position: OWNER PHARMACIST
Credential: R.PH.
Phone: 417-868-8288