Healthcare Provider Details

I. General information

NPI: 1114205333
Provider Name (Legal Business Name): CUSTOM CHEMISTS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 SPRUCE ST UNIT A
CEDARHURST NY
11516-1923
US

IV. Provider business mailing address

127 SPRUCE ST UNIT A
CEDARHURST NY
11516-1923
US

V. Phone/Fax

Practice location:
  • Phone: 516-341-0500
  • Fax: 516-341-0501
Mailing address:
  • Phone: 516-341-0500
  • Fax: 516-341-0501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number030608
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number030608
License Number StateNY

VIII. Authorized Official

Name: DANIEL ZINKOVSKY
Title or Position: SUPERVISING PHARMACIST
Credential: PHARMD
Phone: 516-341-0500