=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558498634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABL CUSTOM COMPOUNDING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 11/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 E 4TH ST
-----------------------------------------------------
City | EMPORIUM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15834-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-486-2326
-----------------------------------------------------
Fax | 814-486-1065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 384
-----------------------------------------------------
City | EMPORIUM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15834-0384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-486-2326
-----------------------------------------------------
Fax | 814-486-1065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BLAIR LUNDBERG
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 814-486-2326
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | PP481743
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------