Provider Demographics
NPI:1396056529
Name:CROUCH, RUSSELL A
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
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 1:1210 SMITHVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1678
Mailing Address - Country:US
Mailing Address - Phone:931-473-3778
Mailing Address - Fax:931-473-3790
Practice Address - Street 1:1210 SMITHVILLE HWY
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1678
Practice Address - Country:US
Practice Address - Phone:931-473-3778
Practice Address - Fax:931-473-3790
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist