=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598158701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESTMARK PHARMACY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2015
-----------------------------------------------------
Last Update Date | 03/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1860 HIGHLAND OAKS BLVD
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33559-7353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-428-6963
-----------------------------------------------------
Fax | 813-803-7503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1860 HIGHLAND OAKS BLVD
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33559-7353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-428-6963
-----------------------------------------------------
Fax | 813-803-7503
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | RANDALL MCELHENEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-832-2773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | PH28922
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------