Provider Demographics
NPI:1922328657
Name:CUSTOM RX LLC
Entity Type:Organization
Organization Name:CUSTOM RX LLC
Other - Org Name:CUSTOM RX COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:612-866-2211
Mailing Address - Street 1:6519 NICOLLET AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1669
Mailing Address - Country:US
Mailing Address - Phone:612-866-2211
Mailing Address - Fax:612-866-9217
Practice Address - Street 1:6519 NICOLLET AVE
Practice Address - Street 2:STE 201
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1669
Practice Address - Country:US
Practice Address - Phone:612-866-2211
Practice Address - Fax:612-866-9217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2635283336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy