Provider Demographics
NPI:1073606240
Name:CUSTOM PHARMACY INNOVATIONS INC
Entity Type:Organization
Organization Name:CUSTOM PHARMACY INNOVATIONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOMGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-769-8585
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:NICOMA PARK
Mailing Address - State:OK
Mailing Address - Zip Code:73066-0489
Mailing Address - Country:US
Mailing Address - Phone:405-769-8585
Mailing Address - Fax:405-769-8787
Practice Address - Street 1:10911 NE 23RD
Practice Address - Street 2:
Practice Address - City:NICOMA PARK
Practice Address - State:OK
Practice Address - Zip Code:73066
Practice Address - Country:US
Practice Address - Phone:405-769-8585
Practice Address - Fax:405-769-8787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OK181353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2077070OtherPK
OK200095530AMedicaid
900522503Medicare PIN