Provider Demographics
NPI:1194301374
Name:WADE, CRYSTAL LYNN
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:WADE
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 1:546 FIRST COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6120
Mailing Address - Country:US
Mailing Address - Phone:757-364-7614
Mailing Address - Fax:757-364-7613
Practice Address - Street 1:546 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6120
Practice Address - Country:US
Practice Address - Phone:757-364-7614
Practice Address - Fax:757-364-7613
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician