Provider Demographics
NPI:1588939615
Name:CUSTOM PHARMACY SERVICES LLC
Entity type:Organization
Organization Name:CUSTOM PHARMACY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBASTIANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-997-4276
Mailing Address - Street 1:517 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURYEA
Mailing Address - State:PA
Mailing Address - Zip Code:18642-1323
Mailing Address - Country:US
Mailing Address - Phone:570-213-5561
Mailing Address - Fax:888-676-5833
Practice Address - Street 1:517 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURYEA
Practice Address - State:PA
Practice Address - Zip Code:18642-1323
Practice Address - Country:US
Practice Address - Phone:570-213-5561
Practice Address - Fax:888-676-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4822483336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135415OtherPK