Provider Demographics
NPI:1952759573
Name:SHAW, CRYSTAL (PHARMD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:SHAW
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 1:95 HOCKANUM BLVD
Mailing Address - Street 2:UNIT 4401
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4099
Mailing Address - Country:US
Mailing Address - Phone:603-703-9521
Mailing Address - Fax:
Practice Address - Street 1:37 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-1459
Practice Address - Country:US
Practice Address - Phone:860-684-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist