Provider Demographics
NPI:1699061192
Name:MIX, CRYSTAL M (PHARM D)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:M
Last Name:MIX
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2430
Mailing Address - Country:US
Mailing Address - Phone:727-784-5771
Mailing Address - Fax:
Practice Address - Street 1:900 E LAKE RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-2430
Practice Address - Country:US
Practice Address - Phone:727-784-5771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist