Provider Demographics
NPI:1932231560
Name:CUSTOM MADE PHARMACY INC
Entity Type:Organization
Organization Name:CUSTOM MADE PHARMACY INC
Other - Org Name:SPECIALITY COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHANJASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-308-8314
Mailing Address - Street 1:13322 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13322 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2509
Practice Address - Country:US
Practice Address - Phone:818-789-8111
Practice Address - Fax:818-789-6548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA485343336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5626289OtherNCPDP PROVIDER IDENTIFICATION NUMBER