Provider Demographics
NPI:1699189134
Name:CUSTOM CARE PHARMACY LLC
Entity Type:Organization
Organization Name:CUSTOM CARE PHARMACY LLC
Other - Org Name:CUSTOM CARE PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VISHALI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:661-319-1150
Mailing Address - Street 1:7007 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1001
Mailing Address - Country:US
Mailing Address - Phone:708-628-5464
Mailing Address - Fax:
Practice Address - Street 1:7007 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1001
Practice Address - Country:US
Practice Address - Phone:708-628-5464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.0185883336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146437OtherPK