1669033288 NPI number — SUNCREST PHARMACY GROUP, LLC

Table of content: (NPI 1669033288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669033288 NPI number — SUNCREST PHARMACY GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNCREST PHARMACY GROUP, 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:
1669033288
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ILWACO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98624-0167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-642-3133
Provider Business Mailing Address Fax Number:
360-642-5133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5919F HIGHWAY 291
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NINE MILE FALLS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-413-2030
Provider Business Practice Location Address Fax Number:
509-413-2091
Provider Enumeration Date:
06/25/2019

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
ERIK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
509-455-9345

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2142653 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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