Healthcare Provider Details

I. General information

NPI: 1407144777
Provider Name (Legal Business Name): CUSTOM DOSING NORTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 BEECH ST UNIT R
VALPARAISO IN
46383-6010
US

IV. Provider business mailing address

2701 BEECH ST UNIT R
VALPARAISO IN
46383-6010
US

V. Phone/Fax

Practice location:
  • Phone: 219-465-2181
  • Fax: 219-464-4382
Mailing address:
  • Phone: 219-465-2181
  • Fax: 219-464-4382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number60006264A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number054019539
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEFF BARTON
Title or Position: OWNER
Credential: RPH
Phone: 219-465-2181