Provider Demographics
NPI:1407295728
Name:IDA, CRYSTAL (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:
Last Name:IDA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 WYNNE AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-3340
Mailing Address - Country:US
Mailing Address - Phone:406-560-9893
Mailing Address - Fax:
Practice Address - Street 1:1300 E PARK AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2729
Practice Address - Country:US
Practice Address - Phone:406-563-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist