Basic Information
| Provider Information | |||||||||
| NPI: | 1639495419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORNBACH-POOJARI | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | LE-ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM. D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLACKBURN | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | LE-ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHARM D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 302 TRACI DAWN DR | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654018259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143655735 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4430 MISSOURI AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654739098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735960514 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2010 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 2010028707 | MO | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | NONE | OTHER |