Provider Demographics
NPI:1578848149
Name:CUSTOMPRESCRIPTION
Entity Type:Organization
Organization Name:CUSTOMPRESCRIPTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SRIKANTH
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHIVAKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MPHARM,RPH
Authorized Official - Phone:614-397-6687
Mailing Address - Street 1:1620 E BROAD ST APT 1005
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43203-2027
Mailing Address - Country:US
Mailing Address - Phone:614-397-6687
Mailing Address - Fax:
Practice Address - Street 1:1620 E BROAD ST APT 1005
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-2027
Practice Address - Country:US
Practice Address - Phone:614-397-6687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03128002183500000X
MI5302037600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty