Provider Demographics
NPI:1437336989
Name:RED CROWN CLINIC PHARMACY, INC
Entity type:Organization
Organization Name:RED CROWN CLINIC PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-321-4800
Mailing Address - Street 1:4206 STADIUM DR
Mailing Address - Street 2:SUITE-2
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1446
Mailing Address - Country:US
Mailing Address - Phone:269-321-4800
Mailing Address - Fax:269-321-4801
Practice Address - Street 1:4206 STADIUM DR
Practice Address - Street 2:SUITE-2
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1446
Practice Address - Country:US
Practice Address - Phone:269-321-4800
Practice Address - Fax:269-321-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010088203336S0011X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy