Organization
CUSTOMCEUTICAL COMPOUNDING, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JAMES W BURCH (PARTNER)
(480) 516-0272
Entity
Organization
Contact information
Practice address
4611 E SHEA BLVD, BLDG 3, STE 180, PHOENIX, AZ 85028
(480) 516-0272
Mailing address
4611 E SHEA BLVD, BLDG 3, STE 180, PHOENIX, AZ 85028-4254
(480) 516-0272
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
Y005317
AZ
3336C0004X
Compounding Pharmacy
Y005317
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
960917
—
AZ
Enumeration date
04/12/2011
Last updated
08/29/2018
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