Provider Demographics
NPI:1669539920
Name:ELMORE, CHARLES EDWARD (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:ELMORE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9366 NEWBURG CT
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-9755
Mailing Address - Country:US
Mailing Address - Phone:517-423-3896
Mailing Address - Fax:
Practice Address - Street 1:1450 W CHICAGO BLVD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-8727
Practice Address - Country:US
Practice Address - Phone:517-424-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302019908183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist