=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326573742
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD J CROWE RPH, BCNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2017
-----------------------------------------------------
Last Update Date | 04/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1841 CLIFTON RD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30329-4021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-712-4664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 HERRING RD
-----------------------------------------------------
City | GRAYSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30017-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-712-4664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS26170
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1835N0905X
-----------------------------------------------------
Taxonomy Name | Nuclear Pharmacist
-----------------------------------------------------
License Number | 16456
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------