Provider Demographics
NPI:1609896091
Name:TIBERIUS
Entity Type:Organization
Organization Name:TIBERIUS
Other - Org Name:CUSTOM SRIPTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-871-6154
Mailing Address - Street 1:27732 CASHFORD CIR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6964
Mailing Address - Country:US
Mailing Address - Phone:813-871-6154
Mailing Address - Fax:813-876-9095
Practice Address - Street 1:27732 CASHFORD CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6964
Practice Address - Country:US
Practice Address - Phone:813-871-6154
Practice Address - Fax:813-876-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH139383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1022348OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1152890001Medicare NSC