Healthcare Provider Details

I. General information

NPI: 1891068243
Provider Name (Legal Business Name): CRYSTAL D. HEISE PHARM.D., BCOP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL D. MAYLES PHARM.D.

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 FOUNDATION WAY STE 2600
MARTINSBURG WV
25401-9197
US

IV. Provider business mailing address

2000 FOUNDATION WAY STE 2600
MARTINSBURG WV
25401-9197
US

V. Phone/Fax

Practice location:
  • Phone: 304-264-1000
  • Fax:
Mailing address:
  • Phone: 304-264-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH100001693
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRP446057
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPI005878
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number22227
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0202212488
License Number StateVA
# 6
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License NumberRP0007760
License Number StateWV
# 7
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRP0007760
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: