Provider Demographics
NPI:1790877942
Name:CRYSTAL PHARMACY LLC
Entity Type:Organization
Organization Name:CRYSTAL PHARMACY LLC
Other - Org Name:CRYSTAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTTY
Authorized Official - Middle Name:
Authorized Official - Last Name:JARVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:229-985-4137
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-0008
Mailing Address - Country:US
Mailing Address - Phone:229-985-4137
Mailing Address - Fax:229-890-5968
Practice Address - Street 1:705 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-5432
Practice Address - Country:US
Practice Address - Phone:229-985-4137
Practice Address - Fax:229-890-5968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
GAPHRE0022063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016008OtherPK
GA393761900AMedicaid
5785760001Medicare NSC