Provider Demographics
NPI:1407143811
Name:MCCRUMB, NICOLE ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:MCCRUMB
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:THELEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:330 W JEFFERSON ST
Mailing Address - City:PEWAMO
Mailing Address - State:MI
Mailing Address - Zip Code:48873
Mailing Address - Country:US
Mailing Address - Phone:517-282-1030
Mailing Address - Fax:
Practice Address - Street 1:1339 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875
Practice Address - Country:US
Practice Address - Phone:517-647-4704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038885183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist