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General NPI Number Information
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NPI Number | 1285988287
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Entity Type | Organization
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Legal Business Name | CUSTOM CARE COMPOUNDING PHARMACY, INC.
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Dates
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Enumeration Date | 10/30/2012
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Last Update Date | 10/30/2012
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Provider Practice Location Address
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Address Line | 18080 SAN RAMON VALLEY BLVD SUITE 104
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City | SAN RAMON
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State | CA
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Zip | 94583-4437
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Country | US
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Telephone | 925-962-5303
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Fax |
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Provider Business Mailing Address
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Address Line | 18080 SAN RAMON VALLEY BLVD SUITE 104
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City | SAN RAMON
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State | CA
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Zip | 94583-4437
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Country | US
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Telephone | 925-962-5303
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | MISS REGINA WOEGER
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Credential |
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Telephone | 925-962-5303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY51117
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License Number State | CA
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