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General NPI Number Information
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NPI Number | 1083770978
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Entity Type | Organization
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Legal Business Name | SPECIALTY MEDICINE COMPOUNDING PHARMACY
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 04/19/2013
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Provider Practice Location Address
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Address Line | 350 S LAFAYETTE ST
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City | SOUTH LYON
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State | MI
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Zip | 48178-1814
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Country | US
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Telephone | 248-446-2643
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Fax | 248-486-1906
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Provider Business Mailing Address
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Address Line | 350 S LAFAYETTE ST
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City | SOUTH LYON
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State | MI
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Zip | 48178-1814
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Country | US
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Telephone | 248-446-2643
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Fax | 248-486-1906
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Authorized Official
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Title or Position | OWNER
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Name | MR. KENNY RAY WALKUP JR.
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Credential | RPH
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Telephone | 248-446-2643
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number | 5301007610
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License Number State | MI
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