Provider Demographics
NPI:1104227602
Name:CUSTOM SCRIPT PHARMACY
Entity type:Organization
Organization Name:CUSTOM SCRIPT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESPIRATORY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:1304-733-3784
Mailing Address - Street 1:3738 TEAYS VALLEY RD STE C
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9705
Mailing Address - Country:US
Mailing Address - Phone:130-473-3378
Mailing Address - Fax:130-473-3139
Practice Address - Street 1:3738 TEAYS VALLEY RD STE C
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:130-473-3378
Practice Address - Fax:130-473-3139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7117770001Medicare UPIN