Provider Demographics
NPI:1447577051
Name:KREIS, MARK ALLAN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLAN
Last Name:KREIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4232 149TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-3313
Mailing Address - Country:US
Mailing Address - Phone:708-389-9661
Mailing Address - Fax:
Practice Address - Street 1:4232 149TH ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-3313
Practice Address - Country:US
Practice Address - Phone:708-389-9661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-031965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist