Healthcare Provider Details

I. General information

NPI: 1255780441
Provider Name (Legal Business Name): CRISP & ASSOCIATES II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4980 PHILLIPS DR
FOREST PARK GA
30297-1472
US

IV. Provider business mailing address

4980 PHILLIPS DR
FOREST PARK GA
30297-1472
US

V. Phone/Fax

Practice location:
  • Phone: 404-362-2990
  • Fax: 404-362-2994
Mailing address:
  • Phone: 404-362-2990
  • Fax: 404-362-2994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHHH000063
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberPHHH000063
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPHHH000063
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHHH000063
License Number StateGA

VIII. Authorized Official

Name: MR. RAY WAYNE CRISP
Title or Position: OWNER
Credential: RPH
Phone: 404-362-2990