Provider Demographics
NPI:1710367545
Name:CROUCH, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:CROUCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W BROADDUS AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:VA
Mailing Address - Zip Code:22427-9404
Mailing Address - Country:US
Mailing Address - Phone:804-633-5058
Mailing Address - Fax:804-633-0023
Practice Address - Street 1:104 W BROADDUS AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:VA
Practice Address - Zip Code:22427-9404
Practice Address - Country:US
Practice Address - Phone:804-633-5058
Practice Address - Fax:804-633-0023
Is Sole Proprietor?:No
Enumeration Date:2015-06-06
Last Update Date:2015-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202212160183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist