Healthcare Provider Details

I. General information

NPI: 1841691771
Provider Name (Legal Business Name): CRESCENT UNITED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 ENCHANTED PKWY SUITE 100
MANCHESTER MO
63021-5491
US

IV. Provider business mailing address

140 ENCHANTED PKWY SUITE 100
MANCHESTER MO
63021-5491
US

V. Phone/Fax

Practice location:
  • Phone: 636-675-1123
  • Fax:
Mailing address:
  • Phone: 636-675-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2014032156
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2014032156
License Number StateMO

VIII. Authorized Official

Name: DR. IHTESHAM GOHAR
Title or Position: OWNER
Credential: PHARMD
Phone: 636-675-1123