Provider Demographics
NPI:1225676794
Name:CUSTODIO, MICHAELENE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MICHAELENE
Middle Name:
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3514 W CARY ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-2729
Mailing Address - Country:US
Mailing Address - Phone:804-355-8533
Mailing Address - Fax:
Practice Address - Street 1:3514 W CARY ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-2729
Practice Address - Country:US
Practice Address - Phone:804-355-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2023-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80868183500000X
VA0202220240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist