Provider Demographics
NPI:1225049893
Name:CCD OPERATING LLC DBA CRESCENT CENTER DRUGS
Entity Type:Organization
Organization Name:CCD OPERATING LLC DBA CRESCENT CENTER DRUGS
Other - Org Name:CRESCENT CENTER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:KRAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:423-586-6263
Mailing Address - Street 1:228 NORTH FAIRMONT AVAE
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814
Mailing Address - Country:US
Mailing Address - Phone:423-586-6263
Mailing Address - Fax:423-587-5460
Practice Address - Street 1:228 NORTH FAIRMONT AVAE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814
Practice Address - Country:US
Practice Address - Phone:423-586-6263
Practice Address - Fax:423-587-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
TN7033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3564207Medicaid
2095811OtherPK
0357230001Medicare NSC