Provider Demographics
NPI:1962413534
Name:CRISSMAN DRUG
Entity type:Organization
Organization Name:CRISSMAN DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:605-426-6551
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:33 MAIN ST
Mailing Address - City:IPSWICH
Mailing Address - State:SD
Mailing Address - Zip Code:57451-0036
Mailing Address - Country:US
Mailing Address - Phone:605-426-6551
Mailing Address - Fax:605-426-6321
Practice Address - Street 1:33 MAIN ST
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:SD
Practice Address - Zip Code:57451
Practice Address - Country:US
Practice Address - Phone:605-426-6551
Practice Address - Fax:605-426-6321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336L0003X
SD10000003333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4301470OtherOTHER ID NUMBER-COMMERCIAL NUMBER
SD8500872Medicaid
SD9161382Medicaid
4301470OtherOTHER ID NUMBER-COMMERCIAL NUMBER