Provider Demographics
NPI:1104981216
Name:CRIMSON CARE PHARMACY GROUP I., LLC
Entity type:Organization
Organization Name:CRIMSON CARE PHARMACY GROUP I., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:254-694-2249
Mailing Address - Street 1:PO BOX 1126
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-1126
Mailing Address - Country:US
Mailing Address - Phone:254-694-2249
Mailing Address - Fax:254-694-6495
Practice Address - Street 1:203 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692-2302
Practice Address - Country:US
Practice Address - Phone:254-694-2249
Practice Address - Fax:254-694-6495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX126363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143231Medicaid
TX19055070102Medicaid
2096515OtherPK
2096515OtherPK