Provider Demographics
NPI:1720320088
Name:CUSTOM SCRIPT INFUSION VITAL CARE LLC
Entity Type:Organization
Organization Name:CUSTOM SCRIPT INFUSION VITAL CARE LLC
Other - Org Name:CUSTOM SCRIPT INFUSION VITAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-543-3292
Mailing Address - Street 1:3738 TEAYS VALLEY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3738 TEAYS VALLEY RD
Practice Address - Street 2:SUITE B
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:304-543-3292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVMP0552402332B00000X, 332BP3500X, 333600000X, 3336H0001X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7117770001Medicare NSC