Provider Demographics
NPI:1548013329
Name:GRANITE STATE COMPOUNDING AND WELLNESS PHARMACY, LLC
Entity type:Organization
Organization Name:GRANITE STATE COMPOUNDING AND WELLNESS PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:603-325-2556
Mailing Address - Street 1:105 PONEMAH RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-2816
Mailing Address - Country:US
Mailing Address - Phone:603-325-2556
Mailing Address - Fax:
Practice Address - Street 1:105 PONEMAH RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031-2816
Practice Address - Country:US
Practice Address - Phone:603-870-9618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-10
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy