Provider Demographics
NPI:1477029577
Name:CUSTOM RX LLC
Entity Type:Organization
Organization Name:CUSTOM RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-922-4400
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-0246
Mailing Address - Country:US
Mailing Address - Phone:208-922-4400
Mailing Address - Fax:208-922-4499
Practice Address - Street 1:112 4TH ST
Practice Address - Street 2:
Practice Address - City:MELBA
Practice Address - State:ID
Practice Address - Zip Code:83641-5197
Practice Address - Country:US
Practice Address - Phone:208-495-9809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CUSTOM RX LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy