Provider Demographics
NPI:1821442260
Name:CUSTOM CARE PHARMACY LLC
Entity Type:Organization
Organization Name:CUSTOM CARE PHARMACY LLC
Other - Org Name:CUSTOM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCOISE
Authorized Official - Middle Name:
Authorized Official - Last Name:TROTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-267-8555
Mailing Address - Street 1:9332 STATE ROAD 54
Mailing Address - Street 2:#207
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1810
Mailing Address - Country:US
Mailing Address - Phone:727-495-6979
Mailing Address - Fax:
Practice Address - Street 1:9332 STATE ROAD 54 STE 207
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-1810
Practice Address - Country:US
Practice Address - Phone:727-495-6979
Practice Address - Fax:855-855-6979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH28789333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157360OtherPK