Provider Demographics
NPI:1902068216
Name:COMMUNITY COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:COMMUNITY COMPOUNDING PHARMACY
Other - Org Name:COMMUNITY COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-303-7373
Mailing Address - Street 1:6025 JEAN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5307
Mailing Address - Country:US
Mailing Address - Phone:503-303-7373
Mailing Address - Fax:503-344-4996
Practice Address - Street 1:6025 JEAN RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5307
Practice Address - Country:US
Practice Address - Phone:503-303-7373
Practice Address - Fax:503-344-4996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
ORRP0002481CS3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2079590OtherPK