MEDICARE: CAMELBACK COMPOUNDERS 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

General Provider Information

NPI Number	:	1932821493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMELBACK COMPOUNDERS LLC

Provider Business Mailing Address
First Line	:	4416 E CAMELBACK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-2824
Country	:	US
Telephone Number	:	602-840-1111
Fax Number	:	602-840-0111

Provider Business Practice Location Address
First Line	:	4416 E CAMELBACK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-2824
Country	:	US
Telephone Number	:	602-840-1111
Fax Number	:	602-840-0111

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	JACE ANTHONY CLARK
Credential	:	PHARMD
Telephone Number	:	602-840-1111

Provider Enumeration Date	:	09/13/2022
Last Update Date	:	09/13/2022

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