Healthcare Provider Details

I. General information

NPI: 1396011888
Provider Name (Legal Business Name): CUSTOMPP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 W NAVAJO ST STE A
WEST LAFAYETTE IN
47906-1940
US

IV. Provider business mailing address

482 W NAVAJO ST STE A
WEST LAFAYETTE IN
47906-1940
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-2600
  • Fax: 765-463-2601
Mailing address:
  • Phone: 765-463-2600
  • Fax: 765-463-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60006301A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW HUTERA
Title or Position: OWNER
Credential:
Phone: 765-463-2600