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1689714552 NPI number — PROFESSIONAL COMPOUNDING OF ROSWELL INC

NPI Number: 1689714552
Health Care Provider/Practitioner: PROFESSIONAL COMPOUNDING OF ROSWELL INC

Information about “1689714552” NPI (PROFESSIONAL COMPOUNDING OF ROSWELL INC) exists in 1689714552 in HTML format HTML  |  1689714552 in plain Text format TXT  |  1689714552 in PDF (Portable Document Format) PDF  |  1689714552 in an XML format XML  formats.

NPI Number : 1689714552 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1689714552",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "PROFESSIONAL COMPOUNDING OF ROSWELL INC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": "6",
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "700 N UNION AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "ROSWELL",
    "MailingAddressStateName": "NM",
    "MailingAddressPostalCode": "88201-3956",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "575-622-6578",
    "MailingAddressFaxNumber": "575-623-3801",
    "FirstLinePracticeLocationAddress": "700 N UNION AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "ROSWELL",
    "PracticeLocationAddressStateName": "NM",
    "PracticeLocationAddressPostalCode": "88201-3956",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "575-622-6578",
    "PracticeLocationAddressFaxNumber": "575-623-3801",
    "EnumerationDate": "02/08/2007",
    "LastUpdateDate": "08/31/2015",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "SHANNON",
    "AuthorizedOfficialFirstName": "CHARLES",
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": "PRESIDENT",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "RPH",
    "AuthorizedOfficialTelephoneNumber": "575-622-6578",
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "333600000X",
          "TaxonomyName": "Pharmacy",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "3336C0004X",
          "TaxonomyName": "Compounding Pharmacy",
          "LicenseNumber": "PH00002305",
          "LicenseNumberStateCode": "NM",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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