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General NPI Number Information
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NPI Number | 1497963540
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Entity Type | Organization
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Legal Business Name | CUSTOM MED APOTHECARY
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5510 LAFAYETTE RD SUITE 260
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City | INDIANAPOLIS
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State | IN
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Zip | 46254-1685
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Country | US
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Telephone | 317-803-3436
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Fax | 317-803-3437
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Provider Business Mailing Address
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Address Line | 5510 LAFAYETTE RD SUITE 260
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City | INDIANAPOLIS
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State | IN
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Zip | 46254-1685
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Country | US
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Telephone | 317-803-3436
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Fax | 317-803-3437
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Authorized Official
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Title or Position | MEMBER
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Name | JEFF JACKSON
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Credential | R.PH.
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Telephone | 317-803-3436
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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 | 60005496A
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License Number State | IN
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