Provider Demographics
NPI:1194053223
Name:CROCKETT, CHRISTIE SUE (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:SUE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:CHRISTIE
Other - Middle Name:SUE
Other - Last Name:VONGSURITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD, RPH
Mailing Address - Street 1:8202 CULEBRA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-1686
Mailing Address - Country:US
Mailing Address - Phone:210-543-8419
Mailing Address - Fax:210-543-8425
Practice Address - Street 1:8202 CULEBRA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1686
Practice Address - Country:US
Practice Address - Phone:210-543-8419
Practice Address - Fax:210-543-8425
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2014-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist