Provider Demographics
NPI:1467823815
Name:CUSTOM MED, LLC
Entity Type:Organization
Organization Name:CUSTOM MED, LLC
Other - Org Name:CUSTOM MED PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:INAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHABRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-289-6721
Mailing Address - Street 1:4312 N PULASKI
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641
Mailing Address - Country:US
Mailing Address - Phone:708-289-6721
Mailing Address - Fax:779-803-0170
Practice Address - Street 1:4312 N PULASKI
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641
Practice Address - Country:US
Practice Address - Phone:708-289-6721
Practice Address - Fax:779-803-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054019489333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy