1174657431 NPI number — CRITTENTON MEDICAL PHARMACY, INC

Table of content: (NPI 1174657431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174657431 NPI number — CRITTENTON MEDICAL PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRITTENTON MEDICAL PHARMACY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CRITTENTON MEDICAL PHARMACY
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174657431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1135 W UNIVERSITY DR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48307-1871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-650-2155
Provider Business Mailing Address Fax Number:
248-650-6026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135 W UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48307-1871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-650-2155
Provider Business Practice Location Address Fax Number:
248-650-6026
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DRUSKOVICH
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL PRESIDENT
Authorized Official Telephone Number:
269-226-4890

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5315024981 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7034882 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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