Healthcare Provider Details

I. General information

NPI: 1467703991
Provider Name (Legal Business Name): RX MEDICAL COMPOUNDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3159 ROBERT C BYRD DR
BECKLEY WV
25801-3724
US

IV. Provider business mailing address

3159 ROBERT C BYRD DR
BECKLEY WV
25801-3724
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-6334
  • Fax: 304-255-9011
Mailing address:
  • Phone: 304-255-6334
  • Fax: 304-255-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberSP0552432
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberSP0552432
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberSP0552432
License Number StateWV

VIII. Authorized Official

Name: MICHAEL GERARD POWERS
Title or Position: OWNER
Credential:
Phone: 304-255-6334