MEDICARE: CRYSTAL REIB RPH

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	050379	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	050379	OTHER	NY	PHARMACIST LICENSE #

General Provider Information

NPI Number	:	1841513769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL REIB RPH

Provider Business Mailing Address
First Line	:	1100 CLEMENS CENTER PKWY
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-1563
Country	:	US
Telephone Number	:	607-737-5090
Fax Number	:	607-737-5190

Provider Business Practice Location Address
First Line	:	1100 CLEMENS CENTER PKWY
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-1563
Country	:	US
Telephone Number	:	607-737-5090
Fax Number	:	607-737-5190

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

Provider Enumeration Date	:	03/05/2010
Last Update Date	:	03/05/2010

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