Healthcare Provider Details

I. General information

NPI: 1790925725
Provider Name (Legal Business Name): CUSTOM RX, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 S 8TH AVE STE B
BROKEN BOW NE
68822-2456
US

IV. Provider business mailing address

540 S 8TH AVE STE B
BROKEN BOW NE
68822-2456
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-5602
  • Fax: 308-872-2377
Mailing address:
  • Phone: 308-872-5602
  • Fax: 308-872-2377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2818
License Number StateNE

VII. Legacy identifiers

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

# 1
Identifier2816265
Identifier TypeOTHER
Identifier StateNE
Identifier IssuerNCPDP

VIII. Authorized Official

Name: DR. MIKE D. HOLCOMB
Title or Position: PHARMACIST/OWNER
Credential: PHARMD
Phone: 308-872-5602