Healthcare Provider Details

I. General information

NPI: 1962494385
Provider Name (Legal Business Name): CHRYSTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W 3RD ST
COOKEVILLE TN
38501-2495
US

IV. Provider business mailing address

PO BOX 2707
COOKEVILLE TN
38502-2707
US

V. Phone/Fax

Practice location:
  • Phone: 931-526-4312
  • Fax:
Mailing address:
  • Phone: 931-260-9589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2271
License Number StateTN

VIII. Authorized Official

Name: CLARENCE SMITH
Title or Position: PRESIDENT
Credential: RPH
Phone: 931-526-4612