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General NPI Number Information
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NPI Number | 1497916548
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Entity Type | Organization
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Legal Business Name | CUSTOMIZED MEDICATION, LLC
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Dates
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Enumeration Date | 06/21/2008
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Last Update Date | 04/24/2013
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Provider Practice Location Address
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Address Line | 541 ROSKE DR STE E
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City | ELKHART
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State | IN
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Zip | 46516-9323
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Country | US
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Telephone | 574-522-1940
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Fax | 574-522-1990
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Provider Business Mailing Address
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Address Line | 58147 DIENER DR
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City | GOSHEN
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State | IN
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Zip | 46528-7723
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Country | US
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Telephone | 574-522-1940
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Fax | 574-522-1990
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Authorized Official
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Title or Position | OWNER
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Name | RICHARD SARGENT
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Credential |
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Telephone | 574-522-1940
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 60005663A
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License Number State | IN
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