Provider Demographics
NPI:1689341554
Name:NAOUM, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:NAOUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 RESERVOIR DR STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5197
Mailing Address - Country:US
Mailing Address - Phone:619-996-0619
Mailing Address - Fax:619-877-0110
Practice Address - Street 1:5555 RESERVOIR DR STE 114
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5197
Practice Address - Country:US
Practice Address - Phone:619-996-0619
Practice Address - Fax:619-877-0110
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.023969183500000X
CA85404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist