Provider Demographics
NPI:1013072289
Name:RCR EAST, LLC
Entity Type:Organization
Organization Name:RCR EAST, LLC
Other - Org Name:CUSTOM RX PHARMACY & WELLNESS CONCEPTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRANAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:316-636-9595
Mailing Address - Street 1:2350 N GREENWICH RD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8269
Mailing Address - Country:US
Mailing Address - Phone:316-636-9595
Mailing Address - Fax:316-636-9591
Practice Address - Street 1:2350 N GREENWICH RD
Practice Address - Street 2:SUITE 1000
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8269
Practice Address - Country:US
Practice Address - Phone:316-636-9595
Practice Address - Fax:316-636-9591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2102653336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004631360001Medicaid