=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568802254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIX COMPOUNDING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2013
-----------------------------------------------------
Last Update Date | 06/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7110 E MCDONALD DR SUITE C-1
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85253-5426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-229-3775
-----------------------------------------------------
Fax | 602-749-6610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7110 E MCDONALD DR SUITE C-1
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85253-5426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-229-3775
-----------------------------------------------------
Fax | 602-749-6610
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. COURTNEY FORSTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-229-3775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | Y005618
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------