Provider Demographics
NPI:1508162454
Name:CUSTOMEDICA PHARMACY INC
Entity Type:Organization
Organization Name:CUSTOMEDICA PHARMACY INC
Other - Org Name:CUSTOMEDICA COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAH
Authorized Official - Middle Name:
Authorized Official - Last Name:AFSHAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-939-8008
Mailing Address - Street 1:149 W STATE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4901
Mailing Address - Country:US
Mailing Address - Phone:208-939-8008
Mailing Address - Fax:208-938-1067
Practice Address - Street 1:149 W STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4911
Practice Address - Country:US
Practice Address - Phone:208-939-8008
Practice Address - Fax:208-938-1067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336S0011X
ID1651RP3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128455OtherPK
ID806251800Medicaid
4509190001Medicare NSC