Healthcare Provider Details

I. General information

NPI: 1225638521
Provider Name (Legal Business Name): CRYSTAL KEZAR PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 S LOUISE AVE
SIOUX FALLS SD
57106-0705
US

IV. Provider business mailing address

3209 S LOUISE AVE
SIOUX FALLS SD
57106-0705
US

V. Phone/Fax

Practice location:
  • Phone: 605-362-1602
  • Fax: 605-362-1802
Mailing address:
  • Phone: 605-362-1602
  • Fax: 605-362-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5452
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: