Healthcare Provider Details

I. General information

NPI: 1972012128
Provider Name (Legal Business Name): TRI COUNTY COMPOUNDING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111A N HOFFMAN ST
DALLAS NC
28034-1597
US

IV. Provider business mailing address

111A N HOFFMAN ST
DALLAS NC
28034-1597
US

V. Phone/Fax

Practice location:
  • Phone: 704-922-3001
  • Fax: 704-922-0060
Mailing address:
  • Phone: 704-922-3001
  • Fax: 704-922-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number13359
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number13359
License Number StateNC

VIII. Authorized Official

Name: DR. JOSH HANEY
Title or Position: RX MANAGER
Credential: PHARMD
Phone: 704-922-3001