MEDICARE: CREATIVE PHARMACY SOLUTIONS EAST 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
2	3336C0004X	Compounding Pharmacy
3	333600000X	Pharmacy	PH30191	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2159609	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972500130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE PHARMACY SOLUTIONS EAST LLC

Provider Business Mailing Address
First Line	:	2535 JOHNS PL
Second Line	:
City	:	JAMESTOWN
State	:	NY
Zip	:	14701-9210
Country	:	US
Telephone Number	:	716-720-5121
Fax Number	:	716-708-6248

Provider Business Practice Location Address
First Line	:	7779 STARKEY RD
Second Line	:
City	:	SEMINOLE
State	:	FL
Zip	:	33777-4346
Country	:	US
Telephone Number	:	727-381-9799
Fax Number	:	716-708-6248

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	RICHARD MOON
Credential	:
Telephone Number	:	716-720-5121

Provider Enumeration Date	:	07/02/2005
Last Update Date	:	07/13/2022

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