Provider Demographics
NPI:1821788787
Name:ZUPON, CRYSTAL (PHARMD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ZUPON
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 1:530 N LONDON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4431
Mailing Address - Country:US
Mailing Address - Phone:630-546-6793
Mailing Address - Fax:
Practice Address - Street 1:4781 E ROCKTON RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-8977
Practice Address - Country:US
Practice Address - Phone:815-389-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051305483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist