Provider Demographics
NPI:1669033288
Name:SUNCREST PHARMACY GROUP, LLC
Entity Type:Organization
Organization Name:SUNCREST PHARMACY GROUP, LLC
Other - Org Name:SUNCREST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:509-455-9345
Mailing Address - Street 1:PO BOX B
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-0167
Mailing Address - Country:US
Mailing Address - Phone:360-642-3133
Mailing Address - Fax:360-642-5133
Practice Address - Street 1:5919F HIGHWAY 291
Practice Address - Street 2:
Practice Address - City:NINE MILE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99026
Practice Address - Country:US
Practice Address - Phone:509-413-2030
Practice Address - Fax:509-413-2091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2142653Medicaid