Provider Demographics
NPI:1841691771
Name:CRESCENT UNITED LLC
Entity type:Organization
Organization Name:CRESCENT UNITED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IHTESHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOHAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:636-675-1123
Mailing Address - Street 1:140 ENCHANTED PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5491
Mailing Address - Country:US
Mailing Address - Phone:636-675-1123
Mailing Address - Fax:
Practice Address - Street 1:140 ENCHANTED PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63021-5491
Practice Address - Country:US
Practice Address - Phone:636-675-1123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140321563336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy