Healthcare Provider Details

I. General information

NPI: 1679148613
Provider Name (Legal Business Name): CRYSTAL JANICE PUTT CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 JOE MANN BLVD
MIDLAND MI
48642-8903
US

IV. Provider business mailing address

1956 W NORTH UNION RD
AUBURN MI
48611-9585
US

V. Phone/Fax

Practice location:
  • Phone: 989-835-6364
  • Fax: 989-835-1984
Mailing address:
  • Phone: 989-402-7664
  • Fax: 989-835-1984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303015830
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: