Provider Demographics
NPI:1942512330
Name:CUSTOM PHARMACY LLC
Entity Type:Organization
Organization Name:CUSTOM PHARMACY LLC
Other - Org Name:CUSTOM RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MAMAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HARDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-832-9008
Mailing Address - Street 1:4320 E BROWN RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4082
Mailing Address - Country:US
Mailing Address - Phone:480-832-9008
Mailing Address - Fax:480-832-9167
Practice Address - Street 1:4320 E BROWN RD
Practice Address - Street 2:SUITE 106
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4082
Practice Address - Country:US
Practice Address - Phone:480-832-9008
Practice Address - Fax:480-832-9167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0051913336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy