Basic Information
| Provider Information | |||||||||
| NPI: | 1891868204 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CUSTOM HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PPS INFUSION PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 BRAINERD RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374113603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236970057 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6227 LEE HIGHWAY | ||||||||
| Address2: | SUITE I | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238939335 | ||||||||
| FaxNumber: | 4238939336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEY | ||||||||
| AuthorizedOfficialFirstName: | WANDA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4236970057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251F00000X | 73387 | TN | Y | Agencies | Home Infusion |
ID Information
| ID | Type | State | Issuer | Description | 1452932 | 05 | TN | MEDICAID |