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General NPI Number Information
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NPI Number | 1407965262
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Entity Type | Organization
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Legal Business Name | CRESTVIEW PHARMACY, LLC
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 1116 N FERDON BLVD
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City | CRESTVIEW
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State | FL
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Zip | 32536-1710
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Country | US
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Telephone | 850-683-1111
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Fax | 850-683-1753
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Provider Business Mailing Address
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Address Line | 1116 N FERDON BLVD
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City | CRESTVIEW
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State | FL
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Zip | 32536-1710
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Country | US
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Telephone | 850-683-1111
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Fax | 850-683-1753
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Authorized Official
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Title or Position | COO
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Name | MR. VINCE DAGRAVA
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Credential | PHARMD
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Telephone | 859-552-5013
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH18397
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License Number State | FL
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