MEDICARE: KUSTOM WELLNESS, INC

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	333600000X	Pharmacy

General Provider Information

NPI Number	:	1710403043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KUSTOM WELLNESS, INC

Provider Business Mailing Address
First Line	:	4550 DONALD ROSS RD STE 113
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-5104
Country	:	US
Telephone Number	:	561-469-1558
Fax Number	:

Provider Business Practice Location Address
First Line	:	4550 DONALD ROSS RD STE 113
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-5104
Country	:	US
Telephone Number	:	561-469-1558
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TRACY KIRKPATRICK
Credential	:
Telephone Number	:	561-469-1558

Provider Enumeration Date	:	08/18/2017
Last Update Date	:	07/21/2022

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