Provider Demographics
NPI:1982700779
Name:MEDICINE ROOM
Entity Type:Organization
Organization Name:MEDICINE ROOM
Other - Org Name:MEDICINE ROOM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:CROWE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:248-840-9725
Mailing Address - Street 1:72 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6421
Mailing Address - Country:US
Mailing Address - Phone:248-628-7990
Mailing Address - Fax:248-628-6507
Practice Address - Street 1:72 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6421
Practice Address - Country:US
Practice Address - Phone:248-628-7990
Practice Address - Fax:248-628-6507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010035913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2102167Medicaid