Provider Demographics
NPI:1386346690
Name:COLCLOUGH, CRYSTAL GHAYLAH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:GHAYLAH
Last Name:COLCLOUGH
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 1:6211 COY LANE
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16901 CHENAL PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-5904
Practice Address - Country:US
Practice Address - Phone:501-817-8613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12373183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist