Provider Demographics
NPI:1467979971
Name:CRYSTAL CLINIC ORTHOPAEDIC CENTER, LLC
Entity Type:Organization
Organization Name:CRYSTAL CLINIC ORTHOPAEDIC CENTER, LLC
Other - Org Name:CRYSTAL CLINIC ORTHOPAEDIC CENTER OUTPATIENT PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALDER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-379-5125
Mailing Address - Street 1:444 N MAIN ST FL 1
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44310-3110
Mailing Address - Country:US
Mailing Address - Phone:330-379-5125
Mailing Address - Fax:330-379-9086
Practice Address - Street 1:444 N MAIN ST FL 1
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310-3110
Practice Address - Country:US
Practice Address - Phone:330-379-5125
Practice Address - Fax:330-379-9086
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRYSTAL CLINIC ORTHOPAEDIC CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPMY02264650-03333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3685293OtherNCPDP
OHPMY-022646650-03OtherSTATE OF OHIO BOARD OF PHARMACY
OHPMY-022646650-03OtherSTATE OF OHIO BOARD OF PHARMACY