Provider Demographics
NPI:1962494385
Name:CHRYSTAL INC
Entity Type:Organization
Organization Name:CHRYSTAL INC
Other - Org Name:SMITH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:931-526-4612
Mailing Address - Street 1:PO BOX 2707
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38502-2707
Mailing Address - Country:US
Mailing Address - Phone:931-260-9589
Mailing Address - Fax:
Practice Address - Street 1:100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2495
Practice Address - Country:US
Practice Address - Phone:931-526-4312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
TN22713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3561654Medicaid
4426602OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0217210001Medicare NSC