Provider Demographics
NPI:1053494492
Name:GATES, CRISTAL LEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CRISTAL
Middle Name:LEE
Last Name:GATES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:CRISTAL
Other - Middle Name:LEE
Other - Last Name:FETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:5277 VICTORIA CIR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-7843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5300 EAST AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2387
Practice Address - Country:US
Practice Address - Phone:561-848-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist