Healthcare Provider Details

I. General information

NPI: 1942945175
Provider Name (Legal Business Name): CRESCENT DRUG AND APOTHECARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 S DEAN A MCGEE AVE
WYNNEWOOD OK
73098-7822
US

IV. Provider business mailing address

116 S DEAN A MCGEE AVE
WYNNEWOOD OK
73098-7822
US

V. Phone/Fax

Practice location:
  • Phone: 405-665-4115
  • Fax: 405-665-5666
Mailing address:
  • Phone: 405-665-4115
  • Fax: 405-665-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: RORY FORINASH
Title or Position: PHARMACIST
Credential: PHARM D
Phone: 405-665-4115