Provider Demographics
NPI:1679868509
Name:MOORMAN, CRYSTIE SHEREE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTIE
Middle Name:SHEREE
Last Name:MOORMAN
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 1:131 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-2358
Mailing Address - Country:US
Mailing Address - Phone:662-487-6268
Mailing Address - Fax:662-487-6278
Practice Address - Street 1:110 KEATING RD
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-2900
Practice Address - Country:US
Practice Address - Phone:662-578-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-010210183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1679868509OtherNPI
MS1679868509Medicaid