MEDICARE: BROCK CRYSTAL PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5892974-1701	UT

General Provider Information

NPI Number	:	1316601420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROCK CRYSTAL PHARMD

Provider Business Mailing Address
First Line	:	1017 MEDICAL DR
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-3049
Country	:	US
Telephone Number	:	435-723-5211
Fax Number	:	435-723-6379

Provider Business Practice Location Address
First Line	:	1017 MEDICAL DR
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-3049
Country	:	US
Telephone Number	:	435-723-5211
Fax Number	:	435-723-6379

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2021
Last Update Date	:	10/26/2021

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Directions to “ BROCK CRYSTAL PHARMD” Practice Location

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