Provider Demographics
NPI:1497963540
Name:CUSTOM MED APOTHECARY
Entity Type:Organization
Organization Name:CUSTOM MED APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:317-803-3436
Mailing Address - Street 1:5510 LAFAYETTE RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1685
Mailing Address - Country:US
Mailing Address - Phone:317-803-3436
Mailing Address - Fax:317-803-3437
Practice Address - Street 1:5510 LAFAYETTE RD
Practice Address - Street 2:SUITE 260
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1685
Practice Address - Country:US
Practice Address - Phone:317-803-3436
Practice Address - Fax:317-803-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60005496A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy