Provider Demographics
NPI:1952902645
Name:ROBERTSON, CRYSTAL MICHELLE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:ROBERTSON
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 1:1715 N COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1535
Mailing Address - Country:US
Mailing Address - Phone:580-504-4137
Mailing Address - Fax:
Practice Address - Street 1:1715 N COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1535
Practice Address - Country:US
Practice Address - Phone:580-226-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist