=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578848149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUSTOMPRESCRIPTION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2011
-----------------------------------------------------
Last Update Date | 10/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1620 E BROAD ST APT 1005
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43203-2027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-397-6687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 E BROAD ST APT 1005
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43203-2027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-397-6687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. SRIKANTH M SHIVAKUMAR
-----------------------------------------------------
Credential | M.PHARM,RPH
-----------------------------------------------------
Telephone | 614-397-6687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302037600
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03128002
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------