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General NPI Number Information
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NPI Number | 1932288438
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Entity Type | Organization
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Legal Business Name | CUSTOM PRESCRIPTION SHOPPE LLC
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Dates
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Enumeration Date | 11/03/2006
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Last Update Date | 08/01/2024
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Provider Practice Location Address
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Address Line | 5917 PORTAL WAY
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City | FERNDALE
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State | WA
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Zip | 98248-9361
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Country | US
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Telephone | 360-685-4282
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Fax |
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Provider Business Mailing Address
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Address Line | 5917 PORTAL WAY
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City | FERNDALE
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State | WA
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Zip | 98248-9361
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KEVIN FARIS
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Credential |
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Telephone | 360-685-4282
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding 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 | 3336M0002X
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Taxonomy Name | Mail Order 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 | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | CF00057668
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License Number State | WA
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