Provider Demographics
NPI:1477813970
Name:CUSTOM PLUS PHARMACY LLC
Entity type:Organization
Organization Name:CUSTOM PLUS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RACHWAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-463-2600
Mailing Address - Street 1:482 W NAVAJO ST STE A
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1940
Mailing Address - Country:US
Mailing Address - Phone:765-463-2600
Mailing Address - Fax:765-463-2601
Practice Address - Street 1:482 W NAVAJO ST STE A
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1940
Practice Address - Country:US
Practice Address - Phone:765-463-2600
Practice Address - Fax:765-463-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
IN60006301A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1563798OtherNCPDP PROVIDER IDENTIFICATION NUMBER