Organization
FORT WAYNE CUSTOM RX, INC
Active
Other names
Fort Wayne Custom Rx
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GREGORY S RUSSELL PHARM. D (PRESIDENT)
(260) 490-3447
Entity
Organization
Contact information
Practice address
425 E DUPONT RD, FORT WAYNE, IN 46825-2051
(260) 490-3447
(260) 490-3457
Mailing address
425 E DUPONT RD, FORT WAYNE, IN 46825-2051
(260) 490-3447
(260) 490-3457
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
26015397
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201228830A
—
IN
01
—
IN2083
MEDICARE MASS IMMUNIZATION (ROSTER BILLING)
IN
Enumeration date
01/05/2007
Last updated
11/12/2014
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