Healthcare Provider Details

I. General information

NPI: 1497939110
Provider Name (Legal Business Name): EQUINOX COMPOUNDING PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34B WAYS LN
MANCHESTER CENTER VT
05255-9231
US

IV. Provider business mailing address

PO BOX 737
BENNINGTON VT
05201-0737
US

V. Phone/Fax

Practice location:
  • Phone: 802-367-1096
  • Fax: 802-367-1098
Mailing address:
  • Phone: 802-442-5602
  • Fax: 802-442-8023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number0380003389
License Number StateVT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1014827
Identifier TypeMEDICAID
Identifier StateVT
Identifier Issuer
# 2
Identifier2101743
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: PHILIP O NEILL
Title or Position: PRESIDENT
Credential:
Phone: 802-442-5602