Provider Demographics
NPI:1972500130
Name:CREATIVE PHARMACY SOLUTIONS EAST LLC
Entity Type:Organization
Organization Name:CREATIVE PHARMACY SOLUTIONS EAST LLC
Other - Org Name:PHARMACY INNOVATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-720-5121
Mailing Address - Street 1:2535 JOHNS PL
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9210
Mailing Address - Country:US
Mailing Address - Phone:716-720-5121
Mailing Address - Fax:716-708-6248
Practice Address - Street 1:7779 STARKEY RD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33777-4346
Practice Address - Country:US
Practice Address - Phone:727-381-9799
Practice Address - Fax:716-708-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-02
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH30191333600000X, 333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102422500Medicaid
2159609OtherPK