Healthcare Provider Details

I. General information

NPI: 1629004833
Provider Name (Legal Business Name): CROSSETT PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 N LAFAYETTE ST
MACOMB IL
61455-2226
US

IV. Provider business mailing address

PO BOX 464
MACOMB IL
61455-0464
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-2424
  • Fax: 309-836-5541
Mailing address:
  • Phone: 309-833-2424
  • Fax: 309-836-5541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. RICHARD E. CROSSETT
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 309-833-2424