1407965262 NPI number — CRESTVIEW PHARMACY, LLC

Table of content: (NPI 1407965262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407965262 NPI number — CRESTVIEW PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTVIEW PHARMACY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407965262
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1116 N FERDON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESTVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32536-1710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-683-1111
Provider Business Mailing Address Fax Number:
850-683-1753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1116 N FERDON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32536-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-683-1111
Provider Business Practice Location Address Fax Number:
850-683-1753
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAGRAVA
Authorized Official First Name:
VINCE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
859-552-5013

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH18397 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100200027 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 025327800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1094870 . This is a "NCPDP - NAPB" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 109647400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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