Healthcare Provider Details

I. General information

NPI: 1790316719
Provider Name (Legal Business Name): CUSTOM PHARMACY OF NORTH AUGUSTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W MARTINTOWN RD STE 153
NORTH AUGUSTA SC
29841-6135
US

IV. Provider business mailing address

401 W MARTINTOWN RD STE 153
NORTH AUGUSTA SC
29841-6135
US

V. Phone/Fax

Practice location:
  • Phone: 803-693-5514
  • Fax: 803-792-9066
Mailing address:
  • Phone: 803-693-5514
  • Fax: 803-792-9066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: FRANCES MORGAN FORDHAM BLANTON
Title or Position: PHARMACIST IN CHARGE/ CO-OWNER
Credential: PHARMD
Phone: 706-945-8351