Healthcare Provider Details

I. General information

NPI: 1619051380
Provider Name (Legal Business Name): CREST PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8241 SW 124TH ST
PINECREST FL
33156-5900
US

IV. Provider business mailing address

8241 SW 124TH ST
PINECREST FL
33156-5900
US

V. Phone/Fax

Practice location:
  • Phone: 305-253-9191
  • Fax: 305-253-8384
Mailing address:
  • Phone: 305-253-9191
  • Fax: 305-253-8384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GERARDO MIRANDA
Title or Position: PRESIDENT
Credential:
Phone: 305-253-9191