MEDICARE: DR. CRYSTAL THRONE 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	IL051292484	IL

General Provider Information

NPI Number	:	1407204803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRYSTAL THRONE PHARMD

Provider Business Mailing Address
First Line	:	3240 CHICAGO RD
Second Line	:
City	:	SOUTH CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-5421
Country	:	US
Telephone Number	:	708-756-7775
Fax Number	:	708-756-1581

Provider Business Practice Location Address
First Line	:	3240 CHICAGO RD
Second Line	:
City	:	SOUTH CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-5421
Country	:	US
Telephone Number	:	708-756-7775
Fax Number	:	708-756-1581

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

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	05/26/2016

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