MEDICARE: CRAMAR PHARMACY INC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	054.009237	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1450155	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1649212267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRAMAR PHARMACY INC

Provider Business Mailing Address
First Line	:	6104 FOREST BLVD
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-1660
Country	:	US
Telephone Number	:	618-874-1020
Fax Number	:	618-874-0204

Provider Business Practice Location Address
First Line	:	6104 FOREST BLVD
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-1660
Country	:	US
Telephone Number	:	618-874-1020
Fax Number	:	618-874-0204

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	CRAIG HERZOG
Credential	:	RPH
Telephone Number	:	618-874-1020

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	11/29/2010

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Directions to “CRAMAR PHARMACY INC ” Practice Location

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