Provider Demographics
NPI:1407235013
Name:CPPLTC LLC
Entity Type:Organization
Organization Name:CPPLTC LLC
Other - Org Name:CUSTOM PLUS LONG TERM CARE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:654-214-3762
Mailing Address - Street 1:482 W NAVAJO ST STE B
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1940
Mailing Address - Country:US
Mailing Address - Phone:765-607-4103
Mailing Address - Fax:765-607-4109
Practice Address - Street 1:482 W NAVAJO ST STE B
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1940
Practice Address - Country:US
Practice Address - Phone:765-607-4103
Practice Address - Fax:765-607-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy