Organization
MEDFORD COMPOUNDING & SPECIALTY PHARMACY LLC
Active
Other names
Medford Compounding & Specialty Pharmacy LLC
Organization subpart
No
Provider details
NPI number
Authorized official
CRYSTAL KOLLER (VPF)
(631) 475-4141
Entity
Organization
Contact information
Practice address
2612 ROUTE 112, MEDFORD, NY 11763-2522
(631) 693-1403
(631) 654-1508
Mailing address
2608 ROUTE 112, MEDFORD, NY 11763-2551
(631) 475-4141
(631) 475-4911
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0004X
Compounding Pharmacy
Primary
031387
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2136843
PK
—
Enumeration date
08/29/2012
Last updated
04/04/2017
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