Healthcare Provider Details

I. General information

NPI: 1982159133
Provider Name (Legal Business Name): CUSTOMEDICA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 W STATE ST
BOISE ID
83702-3958
US

IV. Provider business mailing address

1915 W STATE ST
BOISE ID
83702-3958
US

V. Phone/Fax

Practice location:
  • Phone: 208-515-2211
  • Fax: 208-515-7989
Mailing address:
  • Phone: 208-515-2211
  • Fax: 208-515-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number43415RP
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW C MURRAY
Title or Position: PRESIDENT
Credential: PHARM.D.
Phone: 208-939-8008