Healthcare Provider Details

I. General information

NPI: 1861782856
Provider Name (Legal Business Name): CUSTOMCEUTICAL COMPOUNDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 E SHEA BLVD BLDG 3, STE 180
PHOENIX AZ
85028
US

IV. Provider business mailing address

4611 E SHEA BLVD BLDG 3, STE 180
PHOENIX AZ
85028-4254
US

V. Phone/Fax

Practice location:
  • Phone: 480-516-0272
  • Fax:
Mailing address:
  • Phone: 480-516-0272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY005317
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberY005317
License Number StateAZ

VIII. Authorized Official

Name: MR. JAMES W BURCH
Title or Position: PARTNER
Credential:
Phone: 480-516-0272