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General NPI Number Information
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NPI Number | 1023190774
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Entity Type | Organization
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Legal Business Name | CUSTOM RX PHARMACY
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 08/24/2009
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Provider Practice Location Address
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Address Line | 731 1/2 N LA BREA AVE
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City | LOS ANGELES
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State | CA
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Zip | 90038-3338
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Country | US
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Telephone | 323-937-7879
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 48408
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City | LOS ANGELES
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State | CA
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Zip | 90048-0408
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Country | US
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Telephone | 323-937-7879
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Fax |
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Authorized Official
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Title or Position | PHARMACIST (PRESIDENT)
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Name | MICHAEL IMANOEL
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Credential |
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Telephone | 323-937-7879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 46817710
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License Number State | CA
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