Healthcare Provider Details

I. General information

NPI: 1588966444
Provider Name (Legal Business Name): INNOVATIVE COMPOUNDING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 CENTER CREST DR SUITE D
WHITSETT NC
27377-8001
US

IV. Provider business mailing address

941 CENTER CREST DR SUITE D
WHITSETT NC
27377-8001
US

V. Phone/Fax

Practice location:
  • Phone: 336-447-4533
  • Fax: 336-447-4810
Mailing address:
  • Phone: 336-447-4533
  • Fax: 336-447-4810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number11414
License Number StateNC

VIII. Authorized Official

Name: JAMES PHILLIPS
Title or Position: OWNER
Credential: RPH
Phone: 803-485-8586