Healthcare Provider Details

I. General information

NPI: 1942512330
Provider Name (Legal Business Name): CUSTOM PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 E BROWN RD SUITE 106
MESA AZ
85205-4082
US

IV. Provider business mailing address

4320 E BROWN RD SUITE 106
MESA AZ
85205-4082
US

V. Phone/Fax

Practice location:
  • Phone: 480-832-9008
  • Fax: 480-832-9167
Mailing address:
  • Phone: 480-832-9008
  • Fax: 480-832-9167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberY005191
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. KAREN KAY HARDMAN
Title or Position: MAMAGER
Credential:
Phone: 480-832-9008