| Organization Name: | ISLAND COMPOUNDING PHARMACY |
| NPI Number: | 1235537770 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LAURA LILE (OWNER) |
| Mailing Address: | 24201 Meridian Rd Suite 1 Grosse Ile |
| State: | MI US |
| Postal Code: | 481382134 |
| Phone Number: | 7343077671 |
| Fax Number: | |
| NPI Enumeration Date: | 12/16/2014 |
| NPI Last Update Date: | 12/16/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 3336C0004X |
| License Number: | 5301007758 |
| 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 |