| Organization Name: | ST. JOHN'S COMPOUNDING LAB, LLC |
| NPI Number: | 1235529520 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LAURA KAY SIMS (PROPRIETOR) |
| Mailing Address: | 3 N Main Ave Lake Placid |
| State: | FL US |
| Postal Code: | 338522603 |
| Phone Number: | 8636344631 |
| Fax Number: | 8634673002 |
| NPI Enumeration Date: | 01/26/2015 |
| NPI Last Update Date: | 01/26/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 3336C0004X |
| License Number: | PH28834 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| 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 |