Fort Wayne Custom RX, Inc

Primary specialty

PharmacistTaxonomy code 183500000X

License

26015397 Issued in IN

Legal business name

FORT WAYNE CUSTOM RX, INC

Doing business as

Fort Wayne Custom Rx

Practice address

425 E Dupont Rd
Fort Wayne, IN 46825-2051

Phone

(260) 490-3447

Fax

(260) 490-3457

NPI assigned

Jan 5, 2007

Last updated

Nov 12, 2014By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Gregory S Russell, PHARM. DNPI 1376897660

Title

President

Phone

(260) 490-3447

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Fort Wayne Custom Rx Doing business as

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Gregory S Russell, PHARM.D

  • Pharmacist
  • Fort Wayne, IN
  • NPI 1376897660
  NPD (past) Authorized official
• Sewlanchi Demeke Tekle-Wold

  • Pharmacist
  • Fort Wayne, IN
  • NPI 1124715230
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167955200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1415750400000",
    "number": "1841347481",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "425 E DUPONT RD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468252051",
            "telephone_number": "260-490-3447",
            "fax_number": "260-490-3457"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "425 E DUPONT RD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468252051",
            "telephone_number": "260-490-3447",
            "fax_number": "260-490-3457"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT WAYNE CUSTOM RX, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-05",
        "last_updated": "2014-11-12",
        "status": "A",
        "authorized_official_last_name": "RUSSELL",
        "authorized_official_first_name": "GREGORY",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "260-490-3447",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHARM. D"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "IN",
            "license": "26015397",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE MASS IMMUNIZATION (ROSTER BILLING)",
            "identifier": "IN2083",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201228830A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fort Wayne Custom Rx",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Pharmacist in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• Pharmacist in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.