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General NPI Number Information
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NPI Number | 1669721239
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Entity Type | Organization
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Legal Business Name | MEDFORD COMPOUNDING & SPECIALTY PHARMACY LLC
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Dates
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Enumeration Date | 08/29/2012
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Last Update Date | 04/04/2017
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Provider Practice Location Address
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Address Line | 2612 ROUTE 112
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City | MEDFORD
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State | NY
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Zip | 11763-2522
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Country | US
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Telephone | 631-693-1403
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Fax | 631-654-1508
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Provider Business Mailing Address
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Address Line | 2608 ROUTE 112
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City | MEDFORD
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State | NY
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Zip | 11763-2551
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Country | US
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Telephone | 631-475-4141
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Fax | 631-475-4911
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Authorized Official
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Title or Position | VPF
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Name | CRYSTAL KOLLER
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Credential |
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Telephone | 631-475-4141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number | 031387
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License Number State | NY
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