Healthcare Provider Details

I. General information

NPI: 1164335055
Provider Name (Legal Business Name): COMPOUNDING CENTER OF WISCONSIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 4TH AVE
KENOSHA WI
53140-4200
US

IV. Provider business mailing address

5710 4TH AVE
KENOSHA WI
53140-4200
US

V. Phone/Fax

Practice location:
  • Phone: 262-476-4644
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0207X
TaxonomyCompounded Sterile Preparations Pharmacist
License Number
License Number State

VIII. Authorized Official

Name: KEYA PATEL
Title or Position: OWNER
Credential:
Phone: 224-717-9482