Provider Demographics
NPI:1750363040
Name:MD CUSTOM COMPOUNDING
Entity type:Organization
Organization Name:MD CUSTOM COMPOUNDING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KEMNER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:513-932-2911
Mailing Address - Street 1:19 N MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1801
Mailing Address - Country:US
Mailing Address - Phone:513-932-2911
Mailing Address - Fax:513-932-4905
Practice Address - Street 1:19 N MECHANIC ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1801
Practice Address - Country:US
Practice Address - Phone:513-932-2911
Practice Address - Fax:513-932-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBM9069279OtherDEA LICENSE NUMBER
OHBM9069279OtherDEA LICENSE NUMBER