Provider Demographics
NPI:1417095407
Name:CUSTOM COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:CUSTOM COMPOUNDING PHARMACY LLC
Other - Org Name:CUSTOM COMPOUNDING PHY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSICK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:423-629-0353
Mailing Address - Street 1:3816 RINGGOLD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37412-1640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3816 RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412-1640
Practice Address - Country:US
Practice Address - Phone:423-629-0353
Practice Address - Fax:423-629-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X
TN00000032953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4432061OtherOTHER ID NUMBER
4432061OtherOTHER ID NUMBER-COMMERCIAL NUMBER