Healthcare Provider Details

I. General information

NPI: 1164631206
Provider Name (Legal Business Name): HERMAN DALE CRABTREE JR. RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BURLINGTON RD
JACKSON OH
45640-9360
US

IV. Provider business mailing address

685 LAKE KATHERINE RD
JACKSON OH
45640-9257
US

V. Phone/Fax

Practice location:
  • Phone: 740-395-8364
  • Fax:
Mailing address:
  • Phone: 740-288-0714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03122747
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-1-22747
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: