Provider Demographics
NPI:1417570078
Name:TUCKER, CRYSTAL
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:
Last Name:TUCKER
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 1:487 CHANTERELLE DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5005
Mailing Address - Country:US
Mailing Address - Phone:770-413-6512
Mailing Address - Fax:
Practice Address - Street 1:303 PEACHTREE CENTER AVE NE STE 600
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1277
Practice Address - Country:US
Practice Address - Phone:844-216-8997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GURPH018924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist