Provider Demographics
NPI:1164104477
Name:LEWIS, CRAIG
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-2645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1903 E 9TH ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-2645
Practice Address - Country:US
Practice Address - Phone:660-359-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023031489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist