=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003278656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUSTOM RX PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2016
-----------------------------------------------------
Last Update Date | 12/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10203A QUEENS BLVD
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-830-4500
-----------------------------------------------------
Fax | 718-830-4505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10203A QUEENS BLVD
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-2857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-830-4500
-----------------------------------------------------
Fax | 718-830-4505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | ALBERT PINKHASOV
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 718-830-4500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 034366
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------