| Organization Name: | SPECIALTY MEDICINE COMPOUNDING PHARMACY |
| NPI Number: | 1083770978 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KENNY RAY WALKUP (OWNER) |
| Mailing Address: | 350 S Lafayette St South Lyon |
| State: | MI US |
| Postal Code: | 481781814 |
| Phone Number: | 2484462643 |
| Fax Number: | 2484861906 |
| NPI Enumeration Date: | 12/28/2006 |
| NPI Last Update Date: | 04/19/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 3336C0004X |
| License Number: | 5301007610 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Pharmacy |
| Taxonomy Specialization: | Compounding Pharmacy |
| Taxonomy Definition: | A pharmacy that specializes in the preparation of components into a drug preparation as the result of a Practitioner |