Healthcare Provider Details

I. General information

NPI: 1811247257
Provider Name (Legal Business Name): PROFESSIONAL SPECIALTY PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 ROXBORO RD
OXFORD NC
27565-2642
US

IV. Provider business mailing address

142 ROXBORO RD
OXFORD NC
27565-2642
US

V. Phone/Fax

Practice location:
  • Phone: 919-603-3824
  • Fax: 919-603-3847
Mailing address:
  • Phone: 919-603-3824
  • Fax: 919-603-3847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number11338
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SUSAN BOWMAN
Title or Position: MEMBER/MANAGER
Credential:
Phone: 919-603-3824