MEDICARE: CRYSTAL PHARIS

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	171W00000X	Contractor
2	171M00000X	Case Manager/Care Coordinator		GA

General Provider Information

NPI Number	:	1942870019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL PHARIS

Provider Business Mailing Address
First Line	:	1727 BOXWOOD PL
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31906-2328
Country	:	US
Telephone Number	:	706-569-0727
Fax Number	:

Provider Business Practice Location Address
First Line	:	1803 7TH ST APT B
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36869-6523
Country	:	US
Telephone Number	:	361-834-9145
Fax Number	:

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

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	03/02/2023

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Directions to “ CRYSTAL PHARIS ” Practice Location

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