Provider Demographics
NPI:1780729988
Name:CUSTOMEDICA PHARMACY, INC
Entity type:Organization
Organization Name:CUSTOMEDICA PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAH
Authorized Official - Middle Name:
Authorized Official - Last Name:AFSHAR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-939-8008
Mailing Address - Street 1:149 W STATE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4959
Mailing Address - Country:US
Mailing Address - Phone:208-939-8008
Mailing Address - Fax:208-938-1067
Practice Address - Street 1:149 W STATE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4959
Practice Address - Country:US
Practice Address - Phone:208-939-8008
Practice Address - Fax:208-938-1067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1651CP3336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1651CPOtherSTATE LICENSE #
ID806251800Medicaid
ID806251800Medicaid
ID806251800Medicaid