Healthcare Provider Details

I. General information

NPI: 1821442260
Provider Name (Legal Business Name): CUSTOM CARE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9332 STATE ROAD 54 STE 207
NEW PORT RICHEY FL
34655-1810
US

IV. Provider business mailing address

9332 STATE ROAD 54 #207
NEW PORT RICHEY FL
34655-1810
US

V. Phone/Fax

Practice location:
  • Phone: 727-495-6979
  • Fax: 855-855-6979
Mailing address:
  • Phone: 727-495-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH28789
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: FRANCOISE TROTMAN
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 727-267-8555