Provider Demographics
NPI:1083709026
Name:JAYHAWK CUSTOM PHARMACY
Entity Type:Organization
Organization Name:JAYHAWK CUSTOM PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONLIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:785-228-9740
Mailing Address - Street 1:6730 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-5650
Mailing Address - Country:US
Mailing Address - Phone:785-228-9740
Mailing Address - Fax:785-228-9745
Practice Address - Street 1:6730 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-5650
Practice Address - Country:US
Practice Address - Phone:785-228-9740
Practice Address - Fax:785-228-9745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-09414332BX2000X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2-09414OtherSTATE LICENSE NUMBER
BJ5143716OtherDEA REGISTRATION
KS2-09414OtherSTATE LICENSE NUMBER