Provider Demographics
NPI:1669556478
Name:CRESCENT FOODS, INC.
Entity type:Organization
Organization Name:CRESCENT FOODS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRENDAN
Authorized Official - Last Name:DEARIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-658-8660
Mailing Address - Street 1:615 N BREAZEALE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365-1203
Mailing Address - Country:US
Mailing Address - Phone:919-658-8660
Mailing Address - Fax:919-658-8630
Practice Address - Street 1:615 N BREAZEALE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-1203
Practice Address - Country:US
Practice Address - Phone:919-658-8660
Practice Address - Fax:919-658-8630
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRESCENT FOODS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC332B00000X, 3336C0003X
NC08289333600000X
NCNC07867333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0965674Medicaid
NC7074150002Medicare NSC