Provider Demographics
NPI:1093811093
Name:CUSTOM CAR PHARMACY, INC
Entity Type:Organization
Organization Name:CUSTOM CAR PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH ANNE
Authorized Official - Middle Name:MEADE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:336-289-9969
Mailing Address - Street 1:2500 BATTLEGROUND AVE STE C
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-4030
Mailing Address - Country:US
Mailing Address - Phone:336-289-0074
Mailing Address - Fax:336-286-6696
Practice Address - Street 1:2500 BATTLEGROUND AVE STE C
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-4030
Practice Address - Country:US
Practice Address - Phone:336-289-0074
Practice Address - Fax:336-286-6696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC077323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC07732OtherNC PHARMACY PERMIT NUMBER
NC0417922Medicaid
NC3438606OtherNCPDP NUMBER
NC3438606OtherNCPDP NUMBER