Provider Demographics
NPI:1003579673
Name:MAZZOTTI, RICHARD R (RPH)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:MAZZOTTI
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 1:2703 LINCOLN TRL
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-9632
Mailing Address - Country:US
Mailing Address - Phone:217-741-0712
Mailing Address - Fax:
Practice Address - Street 1:315 N WEBSTER ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1555
Practice Address - Country:US
Practice Address - Phone:217-824-8154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.025363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist