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MEDICINE MAN COMPOUNDING CENTER LLC

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Company Details

Name: MEDICINE MAN COMPOUNDING CENTER LLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 09 Dec 2019 (6 years ago)
Financial Date End: 31 Dec 2025
Entity Number: 3703369
Place of Formation: IDAHO
File Number: 690412
ZIP code: 83854
County: Kootenai County
Principal Address: 565 N VEST ST POST FALLS, ID 83854-7066

Agent

Name Role Address
Brian M. Jorgensen Agent 565 N VEST ST, POST FALLS, ID 83854

Manager

Name Role Address Appointed On
Brian M Jorgensen Manager 565 N VEST ST, POST FALLLS, ID 83854 2024-11-04

National Provider Identifier

NPI Number:
1659907962
Certification Date:
2020-03-18

Authorized Person:

Name:
DONALD RAY SMITH
Role:
MANAGING PARNER
Phone:

Taxonomy:

Selected Taxonomy:
3336C0004X - Compounding Pharmacy
Is Primary:
Yes

Contacts:

Fax:
2087736309

Filing

Filing Name Filing Number Filing date
Annual Report 0005962422 2024-11-04
Application for Reinstatement 0005749991 2024-05-29
Dissolution/Revocation - Administrative 0004208018 2021-03-13
Initial Filing 0003703369 2019-12-09

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Date of last update: 17 May 2025

Sources: Idaho Secretary of State