Provider Demographics
NPI:1689363434
Name:COLUMBUS CUSTOM RX, LLC
Entity Type:Organization
Organization Name:COLUMBUS CUSTOM RX, LLC
Other - Org Name:COLUMBUS CUSTOM RX PHARMACY: COMPOUNDING AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARITY
Authorized Official - Middle Name:CALHOUN
Authorized Official - Last Name:WAGENTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-405-3277
Mailing Address - Street 1:3290 WILLIAMS RD STE BANDC
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-5614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3290 WILLIAMS RD STE BANDC
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-5614
Practice Address - Country:US
Practice Address - Phone:706-593-3927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-05
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy