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General NPI Number Information
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NPI Number | 1104088020
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Entity Type | Organization
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Legal Business Name | CUSTOM HEALTH PHARMACY INC
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Dates
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Enumeration Date | 07/01/2008
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Last Update Date | 05/16/2016
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Provider Practice Location Address
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Address Line | 844 WILLARD DR STE 7
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City | GREEN BAY
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State | WI
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Zip | 54304-5265
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Country | US
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Telephone | 920-884-7345
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Fax | 920-884-7346
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Provider Business Mailing Address
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Address Line | 844 WILLARD DR STE 7
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City | GREEN BAY
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State | WI
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Zip | 54304-5265
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Country | US
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Telephone | 920-884-7345
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Fax | 920-884-7346
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Authorized Official
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Title or Position | PHARMACIST/PRESIDENT
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Name | JOHN SOWINSKI
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Credential |
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Telephone | 920-482-3145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number | 9354-42
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License Number State | WI
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