Provider Demographics
NPI:1548257348
Name:EXPERT COMPOUNDING PHARMACY INC
Entity type:Organization
Organization Name:EXPERT COMPOUNDING PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADIEVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-988-7979
Mailing Address - Street 1:6744 BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5532
Mailing Address - Country:US
Mailing Address - Phone:818-988-7979
Mailing Address - Fax:818-787-7256
Practice Address - Street 1:6744 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-5532
Practice Address - Country:US
Practice Address - Phone:818-988-7979
Practice Address - Fax:818-787-7256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336S0011X, 333600000X
CA501243336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122842OtherPK