Provider Demographics
NPI:1568761450
Name:CROWLEY, MARYLOU (RPH)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:CROWLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 MAW BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL
Mailing Address - State:SC
Mailing Address - Zip Code:29630-8950
Mailing Address - Country:US
Mailing Address - Phone:864-506-9023
Mailing Address - Fax:
Practice Address - Street 1:2445 MAW BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CENTRAL
Practice Address - State:SC
Practice Address - Zip Code:29630-8950
Practice Address - Country:US
Practice Address - Phone:864-506-9023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17937183500000X
SC11423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC11423OtherPHARMACY LICENSE