Provider Demographics
NPI:1851456289
Name:SUNCREST PHARMACY INC
Entity Type:Organization
Organization Name:SUNCREST PHARMACY INC
Other - Org Name:SUNCREST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/SEC/TRES
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-599-2159
Mailing Address - Street 1:3121 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3238
Mailing Address - Country:US
Mailing Address - Phone:304-599-2159
Mailing Address - Fax:304-599-4408
Practice Address - Street 1:3121 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3238
Practice Address - Country:US
Practice Address - Phone:304-599-2159
Practice Address - Fax:304-599-4408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05502773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0142311000Medicaid
2109413OtherPK
0397830001Medicare NSC