Healthcare Provider Details

I. General information

NPI: 1447276571
Provider Name (Legal Business Name): CUSTOM COMPOUNDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GRESHAM DR
NORFOLK VA
23507-1901
US

IV. Provider business mailing address

400 GRESHAM DR
NORFOLK VA
23507-1901
US

V. Phone/Fax

Practice location:
  • Phone: 757-622-0222
  • Fax: 757-623-9010
Mailing address:
  • Phone: 757-622-0222
  • Fax: 757-623-9010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201002286
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GINO BORTOLUZZI
Title or Position: OWNER
Credential: RPH
Phone: 757-622-0222