Provider Demographics
NPI:1326318924
Name:CROSSLAND, MARK A (BS RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:CROSSLAND
Suffix:
Gender:M
Credentials:BS RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6577
Mailing Address - Country:US
Mailing Address - Phone:217-527-8408
Mailing Address - Fax:217-527-8413
Practice Address - Street 1:1501 S DIRKSEN PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2128
Practice Address - Country:US
Practice Address - Phone:217-527-8408
Practice Address - Fax:217-528-8413
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL41-1519261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL411519261435Medicaid