Provider Demographics
NPI:1811091879
Name:CUSTOM RX INC
Entity type:Organization
Organization Name:CUSTOM RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRANAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:316-721-2626
Mailing Address - Street 1:3510 N RIDGE RD STE 900
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1225
Mailing Address - Country:US
Mailing Address - Phone:316-721-2626
Mailing Address - Fax:316-721-4823
Practice Address - Street 1:3510 N RIDGE RD STE 900
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1225
Practice Address - Country:US
Practice Address - Phone:316-721-2626
Practice Address - Fax:316-721-4823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000043903336C0004X
ID44645MS3336C0004X
IA44773336C0004X
IL054.0195733336C0004X
IN64001361A3336C0004X
NVPH028743336C0004X
MN2648303336C0004X
GAPHNR0009143336C0004X
NDPHAR14973336C0004X
KS2098673336C0004X
FLPH179043336C0004X
MO20120192173336C0004X
NE7583336C0004X
NC137083336C0004X
AROS024953336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2027079OtherPK
KS100445230CMedicaid