Provider Demographics
NPI:1407965262
Name:CRESTVIEW PHARMACY, LLC
Entity Type:Organization
Organization Name:CRESTVIEW PHARMACY, LLC
Other - Org Name:CRESTVIEW PHARMACY, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGRAVA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:859-552-5013
Mailing Address - Street 1:1116 N FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1710
Mailing Address - Country:US
Mailing Address - Phone:850-683-1111
Mailing Address - Fax:850-683-1753
Practice Address - Street 1:1116 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-1710
Practice Address - Country:US
Practice Address - Phone:850-683-1111
Practice Address - Fax:850-683-1753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH183973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100200027Medicaid
FL025327800Medicaid
FL1094870OtherNCPDP - NAPB
FL1094870OtherNCPDP - NAPB