Provider Demographics
NPI:1598158701
Name:CRESTMARK PHARMACY SERVICES, LLC
Entity Type:Organization
Organization Name:CRESTMARK PHARMACY SERVICES, LLC
Other - Org Name:CRESTMARK PHARMACY SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCELHENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-832-2773
Mailing Address - Street 1:1860 HIGHLAND OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7353
Mailing Address - Country:US
Mailing Address - Phone:813-428-6963
Mailing Address - Fax:813-803-7503
Practice Address - Street 1:1860 HIGHLAND OAKS BLVD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-7353
Practice Address - Country:US
Practice Address - Phone:813-428-6963
Practice Address - Fax:813-803-7503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH289223336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150516OtherPK