Provider Demographics
NPI:1346615184
Name:CRAIG, MARK ALEXANDER (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALEXANDER
Last Name:CRAIG
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 1:6462 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-6411
Mailing Address - Country:US
Mailing Address - Phone:310-487-4400
Mailing Address - Fax:
Practice Address - Street 1:6462 MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:LAKE BALBOA
Practice Address - State:CA
Practice Address - Zip Code:91406-6411
Practice Address - Country:US
Practice Address - Phone:310-487-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist