Healthcare Provider Details

I. General information

NPI: 1033532437
Provider Name (Legal Business Name): MD COMPOUNDING PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4386
US

IV. Provider business mailing address

721 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4386
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-6337
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARIO PETRINO
Title or Position: PHARMACIST
Credential:
Phone: 330-726-6337