Provider Demographics
NPI:1174657431
Name:CRITTENTON MEDICAL PHARMACY, INC
Entity Type:Organization
Organization Name:CRITTENTON MEDICAL PHARMACY, INC
Other - Org Name:CRITTENTON MEDICAL PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REGIONAL PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUSKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-226-4890
Mailing Address - Street 1:1135 W UNIVERSITY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1871
Mailing Address - Country:US
Mailing Address - Phone:248-650-2155
Mailing Address - Fax:248-650-6026
Practice Address - Street 1:1135 W UNIVERSITY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1871
Practice Address - Country:US
Practice Address - Phone:248-650-2155
Practice Address - Fax:248-650-6026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53150249813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7034882Medicaid