Healthcare Provider Details

I. General information

NPI: 1457543167
Provider Name (Legal Business Name): RED CROWN II INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N GRAND ST
SCHOOLCRAFT MI
49087-5110
US

IV. Provider business mailing address

7368 OLDENBURG LN
PORTAGE MI
49024-3036
US

V. Phone/Fax

Practice location:
  • Phone: 269-324-9988
  • Fax:
Mailing address:
  • Phone: 269-655-6878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301008668
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ERIC GRAHAM
Title or Position: OWNER
Credential: RPH
Phone: 269-655-6878