=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407252380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEATHERFORD COMPOUNDING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2014
-----------------------------------------------------
Last Update Date | 11/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2005 FORT WORTH HWY STE 100
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-4780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-599-7781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2005 FORT WORTH HWY STE 100
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-4780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-599-7781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PIC
-----------------------------------------------------
Name | LESLIE STONE
-----------------------------------------------------
Credential | PHARM D
-----------------------------------------------------
Telephone | 817-599-7781
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | 27002
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------