Organization
CUSTOM COMPOUNDS INC
Active
Other names
HAGUE PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
GINO BORTOLUZZI RPH (OWNER)
(757) 622-0222
Entity
Organization
Contact information
Practice address
400 GRESHAM DR, NORFOLK, VA 23507-1901
(757) 622-0222
(757) 623-9010
Mailing address
400 GRESHAM DR, NORFOLK, VA 23507-1901
(757) 622-0222
(757) 623-9010
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
0201002286
VA
3336C0004X
Compounding Pharmacy
—
—
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4808222
NCPDP PROVIDER IDENTIFICATION NUMBER
—
05
—
8515999
—
VA
Enumeration date
07/14/2006
Last updated
10/04/2010
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