Healthcare Provider Details

I. General information

NPI: 1720320088
Provider Name (Legal Business Name): CUSTOM SCRIPT INFUSION VITAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3738 TEAYS VALLEY RD SUITE B
HURRICANE WV
25526-9705
US

IV. Provider business mailing address

3738 TEAYS VALLEY RD SUITE B
HURRICANE WV
25526-9705
US

V. Phone/Fax

Practice location:
  • Phone: 304-543-3292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberMP0552402
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberMP0552402
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberMP0552402
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberMP0552402
License Number StateWV
# 5
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHAD A WALLACE
Title or Position: VP OPERATIONS
Credential: R.PH.
Phone: 304-543-3292