Healthcare Provider Details

I. General information

NPI: 1003003823
Provider Name (Legal Business Name): PURE COMPOUNDING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3072 DICK POND RD STE 2
MYRTLE BEACH SC
29588-6954
US

IV. Provider business mailing address

3072 DICK POND RD STE 2
MYRTLE BEACH SC
29588-6954
US

V. Phone/Fax

Practice location:
  • Phone: 843-293-7979
  • Fax: 843-293-6499
Mailing address:
  • Phone: 843-293-7979
  • Fax: 843-293-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number9639
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MELISSA LEE
Title or Position: OWNER
Credential:
Phone: 843-651-7979