Provider Demographics
NPI:1396319414
Name:SPANG, CRYSTAL ANN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:ANN
Last Name:SPANG
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 1:74377 BRAMLETT LN
Mailing Address - Street 2:
Mailing Address - City:WALLOWA
Mailing Address - State:OR
Mailing Address - Zip Code:97885-8217
Mailing Address - Country:US
Mailing Address - Phone:541-969-6767
Mailing Address - Fax:
Practice Address - Street 1:11619 ISLAND AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-8459
Practice Address - Country:US
Practice Address - Phone:541-963-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61192040183500000X
OR0000000390200000X
IDP9693183500000X
ORRPH-0018553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program