Healthcare Provider Details

I. General information

NPI: 1497035182
Provider Name (Legal Business Name): CUSTOMPRESCRIPTION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 E BROAD ST SUITE 1005
COLUMBUS OH
43203-2072
US

IV. Provider business mailing address

1620 E BROAD ST SUITE 1005
COLUMBUS OH
43203-2072
US

V. Phone/Fax

Practice location:
  • Phone: 614-397-6687
  • Fax:
Mailing address:
  • Phone: 614-397-6687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03128002
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number5302037600
License Number StateMI

VIII. Authorized Official

Name: MR. SRIKANTH M SHIVAKUMAR
Title or Position: PRESIDENT
Credential: M.PHARM, RPH
Phone: 614-397-6687