Provider Demographics
NPI:1285988287
Name:CUSTOM CARE COMPOUNDING PHARMACY, INC.
Entity type:Organization
Organization Name:CUSTOM CARE COMPOUNDING PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-962-5303
Mailing Address - Street 1:18080 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4437
Mailing Address - Country:US
Mailing Address - Phone:925-962-5303
Mailing Address - Fax:
Practice Address - Street 1:18080 SAN RAMON VALLEY BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4437
Practice Address - Country:US
Practice Address - Phone:925-962-5303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY511173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY51117OtherCALIFORNIA STATE LICENSE