Provider Demographics
NPI:1639495419
Name:DORNBACH-POOJARI, CRYSTAL LE-ANN (PHARM D)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LE-ANN
Last Name:DORNBACH-POOJARI
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LE-ANN
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:302 TRACI DAWN DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8259
Mailing Address - Country:US
Mailing Address - Phone:314-365-5735
Mailing Address - Fax:
Practice Address - Street 1:4430 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-0514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE