=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003561192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL TRANG PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2022
-----------------------------------------------------
Last Update Date | 02/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6405 MIRA MESA BLVD STE 210
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121-4146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-701-6565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27082 ONEILL DR APT 1221
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-0986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-960-9626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 82677
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------