=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366889685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL COMPOUNDING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2013
-----------------------------------------------------
Last Update Date | 05/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1306 RTE 33 UNIT #4
-----------------------------------------------------
City | FARMINGDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07727-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-938-5545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1306 RTE 33 UNIT #4
-----------------------------------------------------
City | FARMINGDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07727-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-938-5545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KENNETH KALADA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-938-5545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | 28RS00658700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------