Healthcare Provider Details

I. General information

NPI: 1417095407
Provider Name (Legal Business Name): CUSTOM COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 RINGGOLD RD
CHATTANOOGA TN
37412-1640
US

IV. Provider business mailing address

3816 RINGGOLD RD
CHATTANOOGA TN
37412-1640
US

V. Phone/Fax

Practice location:
  • Phone: 423-629-0353
  • Fax: 423-629-9646
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0000003295
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOE MUSICK
Title or Position: PHARMACIST
Credential: RPH
Phone: 423-629-0353