Provider Demographics
NPI:1730257593
Name:SAN DIEGO COMPOUNDING PHARMACY
Entity type:Organization
Organization Name:SAN DIEGO COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH FACA
Authorized Official - Phone:858-277-8884
Mailing Address - Street 1:5395 RUFFIN ROAD
Mailing Address - Street 2:#104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-277-8884
Mailing Address - Fax:858-277-8889
Practice Address - Street 1:5395 RUFFIN ROAD
Practice Address - Street 2:#104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-277-8884
Practice Address - Fax:858-277-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY992763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy