Provider Demographics
NPI:1891868204
Name:CUSTOM HEALTHCARE
Entity Type:Organization
Organization Name:CUSTOM HEALTHCARE
Other - Org Name:PPS INFUSION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:423-697-0057
Mailing Address - Street 1:3700 BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3603
Mailing Address - Country:US
Mailing Address - Phone:423-697-0057
Mailing Address - Fax:
Practice Address - Street 1:6227 LEE HIGHWAY
Practice Address - Street 2:SUITE I
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-893-9335
Practice Address - Fax:423-893-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN73387251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452932Medicaid
TN1452932Medicaid