Healthcare Provider Details

I. General information

NPI: 1639186265
Provider Name (Legal Business Name): CUSTOM MEDICATION AND COMPLIANCE SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 NEW AIRPORT RD STE C
LAGRANGE GA
30240-1410
US

IV. Provider business mailing address

18 NEW AIRPORT RD STE C
LAGRANGE GA
30240-1410
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-2843
  • Fax: 706-884-8123
Mailing address:
  • Phone: 706-884-2843
  • Fax: 706-884-8123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHRE010299
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier098311415A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier2016320
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: DR. EBELL HSIEH
Title or Position: PHARMACIST-IN-CHARAGE
Credential: PHARM D
Phone: 706-884-2843