Organization
CUSTOMEDICA PHARMACY INC
Active
Other names
CUSTOMEDICA COMPOUNDING CENTER
Organization subpart
No
Provider details
NPI number
Authorized official
SHAH AFSHAR PHARM.D. (CHEIF PHARMACIST)
(208) 939-8008
Entity
Organization
Contact information
Practice address
149 W STATE ST STE 101, EAGLE, ID 83616-4911
(208) 939-8008
(208) 938-1067
Mailing address
149 W STATE ST, SUITE 101, EAGLE, ID 83616-4901
(208) 939-8008
(208) 938-1067
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
—
—
3336C0004X
Compounding Pharmacy
Primary
1651RP
ID
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2128455
PK
—
05
—
806251800
—
ID
Enumeration date
02/09/2011
Last updated
08/17/2016
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