Healthcare Provider Details

I. General information

NPI: 1316773690
Provider Name (Legal Business Name): CRYSTAL CHI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 160
SHIPROCK NM
87420-0160
US

IV. Provider business mailing address

4441 OLD COLLEGE RD APT 8106
BRYAN TX
77801-3534
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax:
Mailing address:
  • Phone: 361-720-0031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1461174
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: