Crystal Run Pharmacy LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

027541 Issued in NY

Legal business name

CRYSTAL RUN PHARMACY LLC

Doing business as

CRYSTAL RUN PHARMACY

Practice address

731 Route 211 E Ste 108
Middletown, NY 10941-1457

Phone

(845) 692-7628

Fax

(845) 692-7644

NPI assigned

Sep 7, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Sandra AgnelloNPI 1174855266

Title

Pharmacist in Charge

Phone

(845) 863-6750

Specialties & licenses 1

Addresses

Other identifiers 3

Other names 1

• CRYSTAL RUN PHARMACY Doing business as

Medicare fee-for-service enrollment

Enrolled in NY2 enrollments

Enrollment records 2

Tax ID family

Crystal Run Pharmacy2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Crystal Run Pharmacy LLC

  • Long Term Care Pharmacy
  • Middletown, NY
  • NPI 1770346793
  NPD tax ID

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Sandra Angela Agnello, R.PH

  • Pharmacist
  • Middletown, NY
  • NPI 1174855266
  NPD Authorized official
• Robin Hilling, PHARM.D.

  • Pharmacist
  • Middletown, NY
  • NPI 1184020356
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1157587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1706832000000",
    "number": "1053414532",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "731 ROUTE 211 E STE 108",
            "city": "MIDDLETOWN",
            "state": "NY",
            "postal_code": "109411457",
            "telephone_number": "845-692-7628",
            "fax_number": "845-692-7644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "731 ROUTE 211 E STE 108",
            "city": "MIDDLETOWN",
            "state": "NY",
            "postal_code": "109411457",
            "telephone_number": "845-692-7628",
            "fax_number": "845-692-7644"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "390 Crystal Run Rd",
            "address_2": "STE 111",
            "address_purpose": "LOCATION",
            "city": "Middletown",
            "state": "NY",
            "postal_code": "109414050",
            "country_code": "US",
            "telephone_number": "845-692-7628",
            "fax_number": "845-692-7644",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "CRYSTAL RUN PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-07",
        "last_updated": "2024-02-02",
        "certification_date": "2024-02-02",
        "status": "A",
        "authorized_official_last_name": "AGNELLO",
        "authorized_official_first_name": "SANDRA",
        "authorized_official_title_or_position": "PHARMACIST IN CHARGE",
        "authorized_official_telephone_number": "845-863-6750"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NY",
            "license": "027541",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2814744",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1053414532",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "3352084",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CRYSTAL RUN PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Crystal Run Healthcare Physicians LLP
• Crystal Run Healthcare Physicians LLP
• Crystal Run Healthcare Physicians LLP
• Crystal Run Healthcare Physicians LLP
• Crystal Run Medical Services PC
• Crystal Run Pharmacy LLC
• Crystal Run Village
• Crystal Run Village Inc
• Crystal Run Village Inc
• Crystal Run Village, Inc

• Community/Retail Pharmacy in Middletown, NY
• Providers in Middletown, NY by specialty
• Community/Retail Pharmacy in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 2, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.