Provider Demographics
NPI:1902526817
Name:MOUNTAINSIDE COMPOUNDING LLC
Entity Type:Organization
Organization Name:MOUNTAINSIDE COMPOUNDING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAYNA
Authorized Official - Middle Name:MAUREEN
Authorized Official - Last Name:TIMMER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:678-454-2323
Mailing Address - Street 1:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:TATE
Mailing Address - State:GA
Mailing Address - Zip Code:30177-0254
Mailing Address - Country:US
Mailing Address - Phone:678-454-2323
Mailing Address - Fax:678-454-2325
Practice Address - Street 1:4875 HWY 53 E
Practice Address - Street 2:SUITE B
Practice Address - City:TATE
Practice Address - State:GA
Practice Address - Zip Code:30177
Practice Address - Country:US
Practice Address - Phone:678-454-2323
Practice Address - Fax:678-454-2325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy