=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750167441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRYSTAL ELIZABETH COMMONS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2023
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6625 DIXIE HWY
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346-3422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-620-8700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7528 CADILLAC AVE
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48091-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-944-1285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 5302415445
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------