Provider Demographics
NPI:1770346793
Name:CRYSTAL RUN PHARMACY LLC
Entity type:Organization
Organization Name:CRYSTAL RUN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:AGNELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-692-7628
Mailing Address - Street 1:731 ROUTE 211 E
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-1445
Mailing Address - Country:US
Mailing Address - Phone:845-692-7628
Mailing Address - Fax:845-692-7644
Practice Address - Street 1:731 ROUTE 211 E
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-1445
Practice Address - Country:US
Practice Address - Phone:845-692-7628
Practice Address - Fax:845-692-7644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy