Provider Demographics
NPI:1629150404
Name:CRAIN'S PHARMACY INC
Entity Type:Organization
Organization Name:CRAIN'S PHARMACY INC
Other - Org Name:CRAIN'S PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES PHCST
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-635-2232
Mailing Address - Street 1:251 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:TN
Mailing Address - Zip Code:38063-1736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-1736
Practice Address - Country:US
Practice Address - Phone:731-635-2232
Practice Address - Fax:731-635-8939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN00000010863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3512649Medicaid
4401458OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TN3512649Medicaid