Provider Demographics
NPI:1942375670
Name:CRJ PHARMACY, INC.
Entity type:Organization
Organization Name:CRJ PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:ORVILLE
Authorized Official - Last Name:O'BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-669-1329
Mailing Address - Street 1:1845 N CRYSTAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5902
Mailing Address - Country:US
Mailing Address - Phone:863-669-1329
Mailing Address - Fax:863-669-1521
Practice Address - Street 1:1845 N CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5902
Practice Address - Country:US
Practice Address - Phone:863-669-1329
Practice Address - Fax:863-669-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH21511302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization