Healthcare Provider Details

I. General information

NPI: 1235402686
Provider Name (Legal Business Name): MONTY DALE CROWDES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR R 2B417
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR R 2B417
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7657
  • Fax:
Mailing address:
  • Phone: 707-423-7657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17168
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: