Healthcare Provider Details

I. General information

NPI: 1801119110
Provider Name (Legal Business Name): CUSTOM SCRIPT INFUSION VITAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

PO BOX 361
CLEARFIELD KY
40313-0361
US

V. Phone/Fax

Practice location:
  • Phone: 304-733-3784
  • Fax: 304-733-1398
Mailing address:
  • Phone: 606-780-0009
  • Fax: 606-780-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberSP0552452
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: NICK HOPKINS
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 304-733-3784