MEDICARE: CRYSTAL NMN CHA 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	390200000X	Student in an Organized Health Care Education/Training Program	3902000000X	NC
2	183500000X	Pharmacist	22066	NC

General Provider Information

NPI Number	:	1336394923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL NMN CHA PHARMD

Provider Business Mailing Address
First Line	:	111 N MERGANSER DR
Second Line	:
City	:	PIKEVILLE
State	:	NC
Zip	:	27863-8117
Country	:	US
Telephone Number	:	828-448-4195
Fax Number	:

Provider Business Practice Location Address
First Line	:	3451 JOHN WILLIAMS RD
Second Line	:
City	:	CONNELLYS SPRINGS
State	:	NC
Zip	:	28612-7338
Country	:	US
Telephone Number	:	828-448-4195
Fax Number	:

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

Provider Enumeration Date	:	11/24/2008
Last Update Date	:	05/20/2017

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