Legacy Compounding Inc

Primary specialty

Compounding PharmacyTaxonomy code 3336C0004X

License

114750 Issued in AL

Legal business name

LEGACY COMPOUNDING INC

Practice address

2422 Danville Rd SW Ste H
Decatur, AL 35603-4221

Phone

(256) 353-1123

Fax

(256) 280-3551

NPI assigned

Nov 14, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Samuel Costello, BS PHARMACYNPI 1629120894

Title

Pharmacist-in Charge

Phone

(256) 353-1123

Specialties & licenses 4

Addresses

Other identifiers 2

Other names 1

• Legacy Compounding Inc. Doing business as

Medicare fee-for-service enrollment

Enrolled in AL

Enrollment records 1

Tax ID family

Legacy Compouding Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Legacy Compouding Inc.

  • Durable Medical Equipment & Medical Supplies
  • Decatur, AL
  • NPI 1619481306
  NPD tax ID

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Samuel Marion Costello, REG PHARMACIST

  • Pharmacist
  • Decatur, AL
  • NPI 1629120894
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1510617600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1531958400000",
    "number": "1144733072",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2422 DANVILLE RD SW STE H",
            "city": "DECATUR",
            "state": "AL",
            "postal_code": "356034221",
            "telephone_number": "256-353-1123",
            "fax_number": "256-280-3551"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2422 DANVILLE RD SW STE H",
            "city": "DECATUR",
            "state": "AL",
            "postal_code": "356034221",
            "telephone_number": "256-353-1123",
            "fax_number": "256-280-3551"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LEGACY COMPOUNDING INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-11-14",
        "last_updated": "2018-07-19",
        "status": "A",
        "authorized_official_last_name": "COSTELLO",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "PHARMACIST-IN CHARGE",
        "authorized_official_telephone_number": "256-353-1123",
        "authorized_official_credential": "BS PHARMACY"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0004X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Compounding Pharmacy",
            "state": "AL",
            "license": "114750",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2171878",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1144733072",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Legacy Compounding Inc.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Susan Ashley Lecroix, CRNP
• Alexis Faith Lee
• Amanda Lee
• Richard C Lee, RPH
• Legacy Compouding Inc.
• Barri Brittain Lenox, PT
• Lew B. Sample, DMD, Ms, PC
• Melissa Bailey Lewis
• Life Way Systems, Inc
• Benjamin W Light, M.D., F.A.C.S.

• Compounding Pharmacy in Decatur, AL
• Providers in Decatur, AL by specialty
• Compounding Pharmacy in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 19, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.