Healthcare Provider Details

I. General information

NPI: 1245345446
Provider Name (Legal Business Name): CRYSTAL DRUG LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 E ZAVALA ST
CRYSTAL CITY TX
78839-3512
US

IV. Provider business mailing address

PO BOX 1047
RICHMOND TX
77406-0027
US

V. Phone/Fax

Practice location:
  • Phone: 830-374-3436
  • Fax: 830-374-5573
Mailing address:
  • Phone: 291-232-3940
  • Fax: 832-595-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number23104
License Number StateTX

VIII. Authorized Official

Name: COLIN GINGRICH
Title or Position: COMPLIANCE COORDINATOR
Credential:
Phone: 281-232-3940