Provider Demographics
NPI:1790897700
Name:CRESCENT DRUG STORE INC
Entity Type:Organization
Organization Name:CRESCENT DRUG STORE INC
Other - Org Name:CRESCENT DRUG AND APOTH INC PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-665-4115
Mailing Address - Street 1:116 S DEAN A MCGEE AVE
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-7822
Mailing Address - Country:US
Mailing Address - Phone:405-665-4115
Mailing Address - Fax:405-665-5666
Practice Address - Street 1:116 S DEAN A MCGEE AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098-7822
Practice Address - Country:US
Practice Address - Phone:405-665-4115
Practice Address - Fax:405-665-5666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK22-51093336C0003X
OK2251093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2073349OtherPK
OK100232530AMedicaid