MEDICARE: RYAN CROUSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051298516	IL

General Provider Information

NPI Number	:	1144823873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN CROUSE

Provider Business Mailing Address
First Line	:	2700 BROADWAY ST
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2342
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 BROADWAY ST
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2342
Country	:	US
Telephone Number	:	618-242-2074
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2020
Last Update Date	:	11/17/2020

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Directions to “ RYAN CROUSE ” Practice Location

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