Provider Demographics
NPI:1730510074
Name:CUSTOM CARE PHARMACY, LLC
Entity type:Organization
Organization Name:CUSTOM CARE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMICIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-791-3765
Mailing Address - Street 1:132 E NORTHSIDE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-3415
Mailing Address - Country:US
Mailing Address - Phone:601-488-4360
Mailing Address - Fax:877-747-5326
Practice Address - Street 1:132 E NORTHSIDE DR
Practice Address - Street 2:SUITE C
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-3415
Practice Address - Country:US
Practice Address - Phone:601-488-4360
Practice Address - Fax:877-747-5326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
MS07892/2.23336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143363OtherPK