Provider Demographics
NPI:1003402652
Name:CRAINE, MICAH BOWEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:BOWEN
Last Name:CRAINE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 RUTLEDGE PIKE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:TN
Mailing Address - Zip Code:37709-3027
Mailing Address - Country:US
Mailing Address - Phone:865-932-7775
Mailing Address - Fax:
Practice Address - Street 1:1050 RUTLEDGE PIKE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:TN
Practice Address - Zip Code:37709-3027
Practice Address - Country:US
Practice Address - Phone:865-932-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42059183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist