MEDICARE: CRYSTAL CLEM

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	24959	CO

General Provider Information

NPI Number	:	1831971597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL CLEM

Provider Business Mailing Address
First Line	:	4440 TIERRA ROJO DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80926-9306
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4440 TIERRA ROJO DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80926-9306
Country	:	US
Telephone Number	:	719-225-0170
Fax Number	:

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

Provider Enumeration Date	:	10/17/2023
Last Update Date	:	10/10/2024

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Directions to “ CRYSTAL CLEM ” Practice Location

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