Provider Demographics
NPI:1801119110
Name:CUSTOM SCRIPT INFUSION VITAL CARE LLC
Entity type:Organization
Organization Name:CUSTOM SCRIPT INFUSION VITAL CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-733-3784
Mailing Address - Street 1:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40313-0361
Mailing Address - Country:US
Mailing Address - Phone:606-780-0009
Mailing Address - Fax:606-780-0167
Practice Address - Street 1:3738 TEAYS VALLEY RD
Practice Address - Street 2:SUITE C
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:304-733-3784
Practice Address - Fax:304-733-1398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X, 332BP3500X
WVSP05524523336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123986OtherPK
2123986OtherPK