Provider Demographics
NPI:1467794552
Name:CUSTOM HEALTHCARE COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:CUSTOM HEALTHCARE COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ANHVUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-330-8975
Mailing Address - Street 1:24022 CALLE DE LA PLATA STE 510
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3631
Mailing Address - Country:US
Mailing Address - Phone:949-595-2273
Mailing Address - Fax:949-595-2275
Practice Address - Street 1:24022 CALLE DE LA PLATA STE 510
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3631
Practice Address - Country:US
Practice Address - Phone:949-595-2273
Practice Address - Fax:949-595-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519051835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty