MEDICARE: WEATHERFORD COMPOUNDING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0004X	Compounding Pharmacy	27002	TX

General Provider Information

NPI Number	:	1407252380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEATHERFORD COMPOUNDING

Provider Business Mailing Address
First Line	:	2005 FORT WORTH HWY STE 100
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4780
Country	:	US
Telephone Number	:	817-599-7781
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 FORT WORTH HWY STE 100
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4780
Country	:	US
Telephone Number	:	817-599-7781
Fax Number	:

Authorized Official
Title or Position	:	PIC
Name	:	LESLIE STONE
Credential	:	PHARM D
Telephone Number	:	817-599-7781

Provider Enumeration Date	:	11/05/2014
Last Update Date	:	11/05/2014

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Directions to “WEATHERFORD COMPOUNDING ” Practice Location

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