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General NPI Number Information
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NPI Number | 1508162454
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Entity Type | Organization
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Legal Business Name | CUSTOMEDICA PHARMACY INC
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Dates
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Enumeration Date | 02/09/2011
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Last Update Date | 08/17/2016
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Provider Practice Location Address
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Address Line | 149 W STATE ST STE 101
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City | EAGLE
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State | ID
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Zip | 83616-4911
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Country | US
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Telephone | 208-939-8008
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Fax | 208-938-1067
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Provider Business Mailing Address
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Address Line | 149 W STATE ST SUITE 101
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City | EAGLE
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State | ID
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Zip | 83616-4901
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Country | US
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Telephone | 208-939-8008
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Fax | 208-938-1067
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Authorized Official
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Title or Position | CHEIF PHARMACIST
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Name | SHAH AFSHAR
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Credential | PHARM.D.
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Telephone | 208-939-8008
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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 | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number | 1651RP
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License Number State | ID
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