MEDICARE: IONIA PHARMACY, LLC

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	PHY50802	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5643728	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1912266172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IONIA PHARMACY, LLC

Provider Business Mailing Address
First Line	:	9719 CONCORD PASS
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-3706
Country	:	US
Telephone Number	:	615-319-8126
Fax Number	:

Provider Business Practice Location Address
First Line	:	15421 RED HILL AVE
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-7309
Country	:	US
Telephone Number	:	714-408-7628
Fax Number	:	855-884-6642

Authorized Official
Title or Position	:	CEO
Name	:	ALISON CHERNEY
Credential	:
Telephone Number	:	615-319-8126

Provider Enumeration Date	:	05/09/2012
Last Update Date	:	05/09/2012

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