=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871207837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESTVIEW CITY PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2023
-----------------------------------------------------
Last Update Date | 01/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 S FERDON BLVD
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-3722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-428-1057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 852 MELTON RD
-----------------------------------------------------
City | BAKER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32531-5372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER DENSMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-428-1057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------