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General NPI Number Information
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NPI Number | 1689714552
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL COMPOUNDING OF ROSWELL INC
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Dates
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Enumeration Date | 02/08/2007
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Last Update Date | 08/31/2015
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Provider Practice Location Address
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Address Line | 700 N UNION AVE
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City | ROSWELL
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State | NM
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Zip | 88201-3956
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Country | US
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Telephone | 575-622-6578
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Fax | 575-623-3801
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Provider Business Mailing Address
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Address Line | 700 N UNION AVE
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City | ROSWELL
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State | NM
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Zip | 88201-3956
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Country | US
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Telephone | 575-622-6578
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Fax | 575-623-3801
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHARLES SHANNON
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Credential | RPH
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Telephone | 575-622-6578
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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 | PH00002305
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License Number State | NM
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