Provider Demographics
NPI:1932288438
Name:CUSTOM PRESCRIPTION SHOPPE LLC
Entity Type:Organization
Organization Name:CUSTOM PRESCRIPTION SHOPPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-685-4242
Mailing Address - Street 1:1313 E MAPLE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1313 E MAPLE ST
Practice Address - Street 2:STE 101
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5708
Practice Address - Country:US
Practice Address - Phone:360-685-4242
Practice Address - Fax:360-685-4243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0004X, 3336M0002X
WACF000576683336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4930550OtherOTHER ID NUMBER
WA6026835Medicaid
4925190001Medicare NSC