Provider Demographics
NPI:1841880515
Name:CRUMP, CARLY ROSE
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ROSE
Last Name:CRUMP
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 1:4142 AUSTIN BLUFFS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-2928
Mailing Address - Country:US
Mailing Address - Phone:719-244-9783
Mailing Address - Fax:719-266-0739
Practice Address - Street 1:4142 AUSTIN BLUFFS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-2928
Practice Address - Country:US
Practice Address - Phone:719-244-9783
Practice Address - Fax:719-266-0739
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHAT.0006866183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician