Provider Demographics
NPI:1104088020
Name:CUSTOM HEALTH PHARMACY INC
Entity type:Organization
Organization Name:CUSTOM HEALTH PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOWINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-482-3145
Mailing Address - Street 1:844 WILLARD DR STE 7
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5265
Mailing Address - Country:US
Mailing Address - Phone:920-884-7345
Mailing Address - Fax:920-884-7346
Practice Address - Street 1:844 WILLARD DR STE 7
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5265
Practice Address - Country:US
Practice Address - Phone:920-884-7345
Practice Address - Fax:920-884-7346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9354-423336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133536OtherPK