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General NPI Number Information
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NPI Number | 1700636271
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Entity Type | Organization
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Legal Business Name | CUSTOM MED, LLC
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Dates
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Enumeration Date | 03/26/2024
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Last Update Date | 10/02/2024
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Provider Practice Location Address
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Address Line | 3156 N. CLARK
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City | CHICAGO
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State | IL
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Zip | 60657
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Country | US
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Telephone | 773-568-8340
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Fax |
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Provider Business Mailing Address
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Address Line | 3156 N. CLARK
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City | CHICAGO
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State | IL
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Zip | 60657
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Country | US
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Telephone | 708-289-6721
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Fax |
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Authorized Official
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Title or Position | MEMBER, PRESIDENT
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Name | INAS DAHABRA
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Credential |
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Telephone | 708-289-6721
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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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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