Provider Demographics
NPI:1811970775
Name:SUNCREST PHARMACY
Entity type:Organization
Organization Name:SUNCREST PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-594-0132
Mailing Address - Street 1:509 ASHEBROOKE SQ
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 ASHEBROOKE SQ
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-4465
Practice Address - Country:US
Practice Address - Phone:304-594-0132
Practice Address - Fax:304-594-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05511823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0142311002Medicaid
5010145OtherOTHER ID NUMBER
WV0142311002Medicaid