Provider Demographics
NPI:1821375296
Name:CRABTREE, MARY LOUISE ROLDAN (RPH)
Entity Type:Individual
Prefix:
First Name:MARY LOUISE
Middle Name:ROLDAN
Last Name:CRABTREE
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 1:7545 JELLISON CT
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80005-4052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7211 FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80030-4901
Practice Address - Country:US
Practice Address - Phone:303-427-7479
Practice Address - Fax:303-427-7549
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-13
Last Update Date:2011-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COBW7050420Medicaid