Healthcare Provider Details

I. General information

NPI: 1205157724
Provider Name (Legal Business Name): CREST RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 S MAY AVE STE 11
OKLAHOMA CITY OK
73170-2501
US

IV. Provider business mailing address

10601 S MAY AVE STE 11
OKLAHOMA CITY OK
73170-2501
US

V. Phone/Fax

Practice location:
  • Phone: 405-378-7171
  • Fax: 405-378-7173
Mailing address:
  • Phone: 405-378-7171
  • Fax: 405-378-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number75537
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SARA JUSTICE
Title or Position: MANAGER
Credential:
Phone: 405-378-7171