Provider Demographics
NPI:1912739590
Name:CUSTOM PRESCRIPTION SHOPPE LLC
Entity type:Organization
Organization Name:CUSTOM PRESCRIPTION SHOPPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-685-4282
Mailing Address - Street 1:5917 PORTAL WAY
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9361
Mailing Address - Country:US
Mailing Address - Phone:360-685-4282
Mailing Address - Fax:
Practice Address - Street 1:5917 PORTAL WAY
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9361
Practice Address - Country:US
Practice Address - Phone:360-685-4282
Practice Address - Fax:360-685-4283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy