Healthcare Provider Details

I. General information

NPI: 1407965262
Provider Name (Legal Business Name): CRESTVIEW PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 N FERDON BLVD
CRESTVIEW FL
32536-1710
US

IV. Provider business mailing address

1116 N FERDON BLVD
CRESTVIEW FL
32536-1710
US

V. Phone/Fax

Practice location:
  • Phone: 850-683-1111
  • Fax: 850-683-1753
Mailing address:
  • Phone: 850-683-1111
  • Fax: 850-683-1753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH18397
License Number StateFL

VIII. Authorized Official

Name: MR. VINCE DAGRAVA
Title or Position: COO
Credential: PHARMD
Phone: 859-552-5013