MEDICARE: JEFFREY J CUSTIS RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	03209269	OH

General Provider Information

NPI Number	:	1538140991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY J CUSTIS RPH

Provider Business Mailing Address
First Line	:	3293 LINWOOD AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45226-1267
Country	:	US
Telephone Number	:	513-321-8216
Fax Number	:

Provider Business Practice Location Address
First Line	:	9844 WINDISCH RD
Second Line	:
City	:	WEST CHESTER
State	:	OH
Zip	:	45069-3806
Country	:	US
Telephone Number	:	513-759-2818
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	07/08/2007

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