Healthcare Provider Details

I. General information

NPI: 1679868509
Provider Name (Legal Business Name): CRYSTIE SHEREE MOORMAN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 KEATING RD
BATESVILLE MS
38606-2900
US

IV. Provider business mailing address

131 HIGHWAY 51 N
BATESVILLE MS
38606-2358
US

V. Phone/Fax

Practice location:
  • Phone: 662-578-4399
  • Fax:
Mailing address:
  • Phone: 662-487-6268
  • Fax: 662-487-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-010210
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberE-010210
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: