Provider Demographics
NPI:1184744344
Name:CRESTVIEW PHARMACY, LLC
Entity type:Organization
Organization Name:CRESTVIEW PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:512-452-9535
Mailing Address - Street 1:7100 WOODROW AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1802
Mailing Address - Country:US
Mailing Address - Phone:512-452-9535
Mailing Address - Fax:512-452-9583
Practice Address - Street 1:7100 WOODROW AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1802
Practice Address - Country:US
Practice Address - Phone:512-452-9535
Practice Address - Fax:512-452-9583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX278703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110134Medicaid