Provider Demographics
NPI:1255103024
Name:CREDO PHARMACY LLC
Entity type:Organization
Organization Name:CREDO PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TATERA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:702-800-0400
Mailing Address - Street 1:8995 W FLAMINGO RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-0441
Mailing Address - Country:US
Mailing Address - Phone:702-800-4000
Mailing Address - Fax:702-800-0488
Practice Address - Street 1:8995 W FLAMINGO RD STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-0441
Practice Address - Country:US
Practice Address - Phone:702-800-4000
Practice Address - Fax:702-800-0488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-25
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy