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General NPI Number Information
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NPI Number | 1316601420
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Entity Type | Individual
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Provider Name | BROCK CRYSTAL PHARMD
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Gender | Male
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Dates
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Enumeration Date | 10/25/2021
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Last Update Date | 10/26/2021
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Provider Practice Location Address
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Address Line | 1017 MEDICAL DR
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City | BRIGHAM CITY
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State | UT
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Zip | 84302-3049
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Country | US
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Telephone | 435-723-5211
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Fax | 435-723-6379
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Provider Business Mailing Address
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Address Line | 1017 MEDICAL DR
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City | BRIGHAM CITY
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State | UT
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Zip | 84302-3049
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Country | US
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Telephone | 435-723-5211
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Fax | 435-723-6379
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 5892974-1701
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License Number State | UT
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