Healthcare Provider Details

I. General information

NPI: 1689714552
Provider Name (Legal Business Name): PROFESSIONAL COMPOUNDING OF ROSWELL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N UNION AVE
ROSWELL NM
88201-3956
US

IV. Provider business mailing address

700 N UNION AVE
ROSWELL NM
88201-3956
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-6578
  • Fax: 575-623-3801
Mailing address:
  • Phone: 575-622-6578
  • Fax: 575-623-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH00002305
License Number StateNM

VIII. Authorized Official

Name: CHARLES SHANNON
Title or Position: PRESIDENT
Credential: RPH
Phone: 575-622-6578