Healthcare Provider Details

I. General information

NPI: 1336394923
Provider Name (Legal Business Name): CRYSTAL NMN CHA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 05/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 JOHN WILLIAMS RD
CONNELLYS SPRINGS NC
28612-7338
US

IV. Provider business mailing address

111 N MERGANSER DR
PIKEVILLE NC
27863-8117
US

V. Phone/Fax

Practice location:
  • Phone: 828-448-4195
  • Fax:
Mailing address:
  • Phone: 828-448-4195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number3902000000X
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number22066
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: