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General NPI Number Information
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NPI Number | 1225116239
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Entity Type | Organization
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Legal Business Name | CRYSTAL PHARMACY LLC
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 705 SOUTH MAIN ST
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City | MOULTRIE
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State | GA
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Zip | 31768
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Country | US
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Telephone | 229-985-4137
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Fax | 229-890-5968
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Provider Business Mailing Address
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Address Line | PO BOX 8
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City | MOULTRIE
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State | GA
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Zip | 31776-0008
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Country | US
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Telephone | 229-985-4137
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Fax | 229-890-5968
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | SCOTTY JARVIS
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Credential | PHARMD
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Telephone | 229-985-4137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 2206
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License Number State | GA
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