Provider Demographics
NPI:1376840785
Name:CUSTOM COMPOUNDING LLC
Entity Type:Organization
Organization Name:CUSTOM COMPOUNDING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAPRILE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MBA
Authorized Official - Phone:866-606-0440
Mailing Address - Street 1:3 MAPLE ST
Mailing Address - Street 2:PO BOX 632
Mailing Address - City:KENT
Mailing Address - State:CT
Mailing Address - Zip Code:06757-1711
Mailing Address - Country:US
Mailing Address - Phone:866-606-0440
Mailing Address - Fax:
Practice Address - Street 1:3 MAPLE ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:CT
Practice Address - Zip Code:06757-1711
Practice Address - Country:US
Practice Address - Phone:866-606-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY19213336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy