Provider Demographics
NPI:1891075537
Name:CUSTOM CARE PHARMACY
Entity Type:Organization
Organization Name:CUSTOM CARE PHARMACY
Other - Org Name:CUSTOM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-850-9988
Mailing Address - Street 1:57 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:PA
Mailing Address - Zip Code:17847-1110
Mailing Address - Country:US
Mailing Address - Phone:570-246-5700
Mailing Address - Fax:570-524-1386
Practice Address - Street 1:57 S FRONT ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:PA
Practice Address - Zip Code:17847-1110
Practice Address - Country:US
Practice Address - Phone:570-246-5700
Practice Address - Fax:570-246-5705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
PAPP4822133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132654OtherPK
6641850001Medicare NSC
6641850001Medicare NSC