Organization Name: | CUSTOM RX |
NPI Number: | 1457682114 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | TRAVIS WALTHALL (PHARMACIST/MANAGER) |
Mailing Address: | 173 W 4th St Kuna |
State: | ID US |
Postal Code: | 836342046 |
Phone Number: | 2089224400 |
Fax Number: | 2089224499 |
NPI Enumeration Date: | 01/20/2010 |
NPI Last Update Date: | 03/07/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 3336C0004X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | |
Taxonomy Type: | Suppliers |
Taxonomy Classification: | Pharmacy |
Taxonomy Specialization: | Compounding Pharmacy |
Taxonomy Definition: | A pharmacy that specializes in the preparation of components into a drug preparation as the result of a Practitioner |