Provider Demographics
NPI:1972672822
Name:SKICO INC
Entity Type:Organization
Organization Name:SKICO INC
Other - Org Name:MILLERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MNGR
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:260-463-7464
Mailing Address - Street 1:420 S DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-2310
Mailing Address - Country:US
Mailing Address - Phone:260-463-7464
Mailing Address - Fax:260-463-8150
Practice Address - Street 1:420 S DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2310
Practice Address - Country:US
Practice Address - Phone:260-463-7464
Practice Address - Fax:260-463-8150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60005484A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200259580AMedicaid
2024261OtherPK
2024261OtherPK