Healthcare Provider Details

I. General information

NPI: 1902068216
Provider Name (Legal Business Name): COMMUNITY COMPOUNDING PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 JEAN RD
LAKE OSWEGO OR
97035-5307
US

IV. Provider business mailing address

6025 JEAN RD
LAKE OSWEGO OR
97035-5307
US

V. Phone/Fax

Practice location:
  • Phone: 503-303-7373
  • Fax: 503-344-4996
Mailing address:
  • Phone: 503-303-7373
  • Fax: 503-344-4996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberRP0002481CS
License Number StateOR

VIII. Authorized Official

Name: SUZANNE ROSENBERG
Title or Position: OWNER
Credential: RPH
Phone: 503-303-7373