Healthcare Provider Details

I. General information

NPI: 1679514558
Provider Name (Legal Business Name): BRIAN THOMAS CRYDER PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9831 S WESTERN AVE
CHICAGO IL
60643-1791
US

IV. Provider business mailing address

14511 CENTRAL CT UNIT PH4
OAK FOREST IL
60452-1065
US

V. Phone/Fax

Practice location:
  • Phone: 773-881-5632
  • Fax:
Mailing address:
  • Phone: 708-489-2761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number03-2-25261
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: