Provider Demographics
NPI:1053656835
Name:CRAYCRAFT, MICHAEL ELLIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ELLIS
Last Name:CRAYCRAFT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 WOODLYN DR S
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-4323
Mailing Address - Country:US
Mailing Address - Phone:561-703-1788
Mailing Address - Fax:
Practice Address - Street 1:792 WOODLYN DR S
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4323
Practice Address - Country:US
Practice Address - Phone:561-703-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03221310183500000X
FLPS 33409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist