Provider Demographics
NPI:1811528995
Name:CRAWFORD DRUG LLC
Entity type:Organization
Organization Name:CRAWFORD DRUG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:617-436-3400
Mailing Address - Street 1:1735 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2535
Mailing Address - Country:US
Mailing Address - Phone:617-436-3400
Mailing Address - Fax:
Practice Address - Street 1:1735 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-2535
Practice Address - Country:US
Practice Address - Phone:617-436-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-28
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110106701AMedicaid