MEDICARE: DR. CRYSTAL ANN SPANG PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PH61192040	WA
2	390200000X	Student in an Organized Health Care Education/Training Program	0000000	OR
3	183500000X	Pharmacist	P9693	ID
4	183500000X	Pharmacist	RPH-0018553	OR

General Provider Information

NPI Number	:	1396319414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRYSTAL ANN SPANG PHARMD

Provider Business Mailing Address
First Line	:	74377 BRAMLETT LN
Second Line	:
City	:	WALLOWA
State	:	OR
Zip	:	97885-8217
Country	:	US
Telephone Number	:	541-969-6767
Fax Number	:

Provider Business Practice Location Address
First Line	:	11619 ISLAND AVE
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-8459
Country	:	US
Telephone Number	:	541-963-5460
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2021
Last Update Date	:	12/26/2024

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