Provider Demographics
NPI:1861581415
Name:MAHONEYS COMPOUNDING PHARMACY LLC
Entity type:Organization
Organization Name:MAHONEYS COMPOUNDING PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:913-956-7711
Mailing Address - Street 1:11844 QUIVIRA RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-1300
Mailing Address - Country:US
Mailing Address - Phone:913-956-7711
Mailing Address - Fax:913-956-7722
Practice Address - Street 1:11844 QUIVIRA RD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-1300
Practice Address - Country:US
Practice Address - Phone:913-956-7711
Practice Address - Fax:913-956-7722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
KS2-072933336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100438960AMedicaid
2032533OtherPK