NPIMap

Organization Active NPI

Crystal Pharmacy LLC

  • Pharmacist
  • Moultrie, GA
National Provider Identifier
1225116239
Registry record updated Mar 7, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacistTaxonomy code 183500000X
License
2206 Issued in GA
Legal business name
CRYSTAL PHARMACY LLC
Practice address
705 South Main St
Moultrie, GA 31768
Phone
(229) 985-4137
Fax
(229) 890-5968
NPI assigned
Nov 1, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2023

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

Authorized official

Name
Scotty Jarvis, PHARMD
Title
Managing Member
Phone
(229) 985-4137

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PharmacistGroup: 193400000X SINGLE SPECIALTY GROUP 183500000X 2206 GA Primary

Addresses

Primary practice location

705 South Main St
Moultrie, GA 31768

Mailing address

PO Box 8
Moultrie, GA 31776-0008
Phone (229) 985-4137

Other identifiers 2

IdentifierTypeStateIssuer
00025605AMedicaidGA
1101942OtherNABP

Other names 1

  • Crystal Pharmacy Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Crystal Pharmacy3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

NPI Registry JSON

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

{
    "created_epoch": "1162339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678147200000",
    "number": "1225116239",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 8",
            "city": "MOULTRIE",
            "state": "GA",
            "postal_code": "317760008",
            "telephone_number": "229-985-4137",
            "fax_number": "229-890-5968"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "705 SOUTH MAIN ST",
            "city": "MOULTRIE",
            "state": "GA",
            "postal_code": "31768",
            "telephone_number": "229-985-4137",
            "fax_number": "229-890-5968"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRYSTAL PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-01",
        "last_updated": "2023-03-07",
        "status": "A",
        "authorized_official_last_name": "JARVIS",
        "authorized_official_first_name": "SCOTTY",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "229-985-4137",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pharmacist",
            "state": "GA",
            "license": "2206",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00025605A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NABP",
            "identifier": "1101942",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crystal Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Moultrie, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.