Provider Demographics
NPI:1770500738
Name:CREST PHARMACY, INC
Entity Type:Organization
Organization Name:CREST PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:641-782-3906
Mailing Address - Street 1:1418 170TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-8355
Mailing Address - Country:US
Mailing Address - Phone:641-782-6125
Mailing Address - Fax:641-782-6125
Practice Address - Street 1:1418 170TH ST
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-8355
Practice Address - Country:US
Practice Address - Phone:641-782-6125
Practice Address - Fax:641-782-6125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA631333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0211060Medicaid
IA0211060Medicaid