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General NPI Number Information
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NPI Number | 1841347481
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Entity Type | Organization
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Legal Business Name | FORT WAYNE CUSTOM RX, INC
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Dates
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Enumeration Date | 01/05/2007
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Last Update Date | 11/12/2014
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Provider Practice Location Address
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Address Line | 425 E DUPONT RD
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City | FORT WAYNE
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State | IN
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Zip | 46825-2051
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Country | US
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Telephone | 260-490-3447
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Fax | 260-490-3457
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Provider Business Mailing Address
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Address Line | 425 E DUPONT RD
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City | FORT WAYNE
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State | IN
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Zip | 46825-2051
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Country | US
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Telephone | 260-490-3447
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Fax | 260-490-3457
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GREGORY S RUSSELL
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Credential | PHARM. D
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Telephone | 260-490-3447
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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 | 26015397
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License Number State | IN
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