Provider Demographics
NPI:1497031678
Name:HAZZARD, ALFRED OTIS JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:OTIS
Last Name:HAZZARD
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9022
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-9022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7815 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2078
Practice Address - Country:US
Practice Address - Phone:309-691-5514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-294943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist