Provider Demographics
NPI:1316601420
Name:CRYSTAL, BROCK (PHARMD)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:CRYSTAL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3049
Mailing Address - Country:US
Mailing Address - Phone:435-723-5211
Mailing Address - Fax:435-723-6379
Practice Address - Street 1:1017 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3049
Practice Address - Country:US
Practice Address - Phone:435-723-5211
Practice Address - Fax:435-723-6379
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5892974-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist