Healthcare Provider Details

I. General information

NPI: 1457682114
Provider Name (Legal Business Name): CUSTOM RX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 W 4TH ST
KUNA ID
83634-2046
US

IV. Provider business mailing address

PO BOX 246
KUNA ID
83634-0246
US

V. Phone/Fax

Practice location:
  • Phone: 208-922-4400
  • Fax: 208-922-4499
Mailing address:
  • Phone: 208-922-4400
  • Fax: 208-922-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2399RP
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TRAVIS WALTHALL
Title or Position: PHARMACIST/MANAGER
Credential:
Phone: 208-631-8141