Provider Demographics
NPI:1588014880
Name:VERTISIS CUSTOM PHARMACY
Entity Type:Organization
Organization Name:VERTISIS CUSTOM PHARMACY
Other - Org Name:VERTISIS CUSTOM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-285-5841
Mailing Address - Street 1:9343 E BAHIA DR
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1559
Mailing Address - Country:US
Mailing Address - Phone:888-285-5841
Mailing Address - Fax:
Practice Address - Street 1:9343 E BAHIA DR
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1559
Practice Address - Country:US
Practice Address - Phone:888-285-5841
Practice Address - Fax:480-625-4276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0070423336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162287OtherPK