Organization
PRESCRIPTION COMPOUNDING SHOPPE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
EDWARD BAISE (PHARMACIST)
(270) 789-2165
Entity
Organization
Contact information
Practice address
327 E BROADWAY ST, CAMPBELLSVILLE, KY 42718-2003
(270) 465-3784
(270) 789-3784
Mailing address
327 E BROADWAY ST, CAMPBELLSVILLE, KY 42718-2003
Taxonomy
Speciality
Code
Description
License number
State
3336C0004X
Compounding Pharmacy
Primary
PO6571
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1830721
OTHER ID NUMBER
—
Enumeration date
06/10/2008
Last updated
06/10/2008
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