MEDICARE: CRESTVIEW PHARMACY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	27870	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184744344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTVIEW PHARMACY, LLC

Provider Business Mailing Address
First Line	:	7100 WOODROW AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-1802
Country	:	US
Telephone Number	:	512-452-9535
Fax Number	:	512-452-9583

Provider Business Practice Location Address
First Line	:	7100 WOODROW AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-1802
Country	:	US
Telephone Number	:	512-452-9535
Fax Number	:	512-452-9583

Authorized Official
Title or Position	:	PHARMACIST
Name	:	MR. JERRY DWAYNE HARPER
Credential	:	RPH.
Telephone Number	:	512-452-9535

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	03/13/2012

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Directions to “CRESTVIEW PHARMACY, LLC ” Practice Location

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