Provider Demographics
NPI:1518019876
Name:MANGRUM, CRYSTAL GAIL (CPHT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GAIL
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:BON AQUA
Mailing Address - State:TN
Mailing Address - Zip Code:37025-0420
Mailing Address - Country:US
Mailing Address - Phone:615-412-3001
Mailing Address - Fax:
Practice Address - Street 1:111 W. KINGSTON SPRINGS RD
Practice Address - Street 2:STE 103
Practice Address - City:KINGSTON SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37082
Practice Address - Country:US
Practice Address - Phone:615-952-3690
Practice Address - Fax:615-952-3692
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14104183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician