Healthcare Provider Details

I. General information

NPI: 1669539920
Provider Name (Legal Business Name): CHARLES EDWARD ELMORE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 W CHICAGO BLVD
TECUMSEH MI
49286-8727
US

IV. Provider business mailing address

9366 NEWBURG CT
TECUMSEH MI
49286-9755
US

V. Phone/Fax

Practice location:
  • Phone: 517-424-1212
  • Fax:
Mailing address:
  • Phone: 517-423-3896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302019908
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: