Basic Information
| Provider Information | |||||||||
| NPI: | 1891068243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEISE | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D., BCOP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYLES | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | D. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHARM.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 MEDICAL CENTER DR | ||||||||
| Address2: | STE 500B | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911787 | ||||||||
| FaxNumber: | 3046911477 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265061200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045984000 | ||||||||
| FaxNumber: | 3045984560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2012 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | PH100001693 | DC | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | RP446057 | PA | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | RPI005878 | PA | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | 22227 | MD | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | 0202212488 | VA | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | RP0007760 | WV | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.