{
"Npi": {
"NPI": "1285988287",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CUSTOM CARE COMPOUNDING PHARMACY, INC.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "18080 SAN RAMON VALLEY BLVD",
"SecondLineMailingAddress": "SUITE 104",
"MailingAddressCityName": "SAN RAMON",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "94583-4437",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "925-962-5303",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "18080 SAN RAMON VALLEY BLVD",
"SecondLinePracticeLocationAddress": "SUITE 104",
"PracticeLocationAddressCityName": "SAN RAMON",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "94583-4437",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "925-962-5303",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "10/30/2012",
"LastUpdateDate": "10/30/2012",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WOEGER",
"AuthorizedOfficialFirstName": "REGINA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CO-OWNER",
"AuthorizedOfficialNamePrefix": "MISS",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "925-962-5303",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "PHY51117",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}