Provider Demographics
NPI:1487857207
Name:CUSTOM PRESCRIPTIONS OF LANCASTER, LLC
Entity Type:Organization
Organization Name:CUSTOM PRESCRIPTIONS OF LANCASTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOOMSMA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:717-393-0518
Mailing Address - Street 1:902 N DUKE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-1906
Mailing Address - Country:US
Mailing Address - Phone:717-393-0518
Mailing Address - Fax:717-393-0519
Practice Address - Street 1:902 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602
Practice Address - Country:US
Practice Address - Phone:717-393-0518
Practice Address - Fax:717-393-0519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4816823336C0003X, 3336C0004X, 3336S0011X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy