Healthcare Provider Details

I. General information

NPI: 1437336989
Provider Name (Legal Business Name): RED CROWN CLINIC PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4206 STADIUM DR SUITE-2
KALAMAZOO MI
49008-1446
US

IV. Provider business mailing address

4206 STADIUM DR SUITE-2
KALAMAZOO MI
49008-1446
US

V. Phone/Fax

Practice location:
  • Phone: 269-321-4800
  • Fax: 269-321-4801
Mailing address:
  • Phone: 269-321-4800
  • Fax: 269-321-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number5301008820
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5301008820
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number5301008820
License Number StateMI

VIII. Authorized Official

Name: MR. ERIC M GRAHAM
Title or Position: PRESIDENT
Credential: RPH
Phone: 269-321-4800