Crestview Pharmacy, LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

PH18397 Issued in FL

Legal business name

CRESTVIEW PHARMACY, LLC

Practice address

1116 N Ferdon Blvd
Crestview, FL 32536-1710

Phone

(850) 683-1111

Fax

(850) 683-1753

NPI assigned

Aug 29, 2006

Organization subpart

No

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

Authorized official

Name

Mr. Vince Dagrava, PHARMD

Title

Coo

Phone

(859) 552-5013

Specialties & licenses 1

Addresses

Other identifiers 3

Other names 1

• Crestview Pharmacy, Inc Former legal business name

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

{
    "created_epoch": "1156809600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560211200000",
    "number": "1407965262",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1116 N FERDON BLVD",
            "city": "CRESTVIEW",
            "state": "FL",
            "postal_code": "325361710",
            "telephone_number": "850-683-1111",
            "fax_number": "850-683-1753"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1116 N FERDON BLVD",
            "city": "CRESTVIEW",
            "state": "FL",
            "postal_code": "325361710",
            "telephone_number": "850-683-1111",
            "fax_number": "850-683-1753"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRESTVIEW PHARMACY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-29",
        "last_updated": "2019-06-11",
        "status": "A",
        "authorized_official_last_name": "DAGRAVA",
        "authorized_official_first_name": "VINCE",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "859-552-5013",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "FL",
            "license": "PH18397",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100200027",
            "state": "AL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "025327800",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP - NAPB",
            "identifier": "1094870",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crestview Pharmacy, Inc",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• Community/Retail Pharmacy in Crestview, FL
• Providers in Crestview, FL by specialty
• Community/Retail Pharmacy in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2019; 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.