MEDICARE: MARIE CRYDERMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302040567	MI

General Provider Information

NPI Number	:	1821634213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE CRYDERMAN

Provider Business Mailing Address
First Line	:	108 W HIGHLAND RD
Second Line	:
City	:	HOWELL
State	:	MI
Zip	:	48843-1159
Country	:	US
Telephone Number	:	517-552-0205
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 W HIGHLAND RD
Second Line	:
City	:	HOWELL
State	:	MI
Zip	:	48843-1159
Country	:	US
Telephone Number	:	517-552-0205
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2019
Last Update Date	:	11/21/2019

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