Provider Demographics
NPI:1497035745
Name:CROCKER, SETH ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:ALAN
Last Name:CROCKER
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 1:18195 EULA MAE PKWY
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-6406
Mailing Address - Country:US
Mailing Address - Phone:618-594-8385
Mailing Address - Fax:618-594-8601
Practice Address - Street 1:18195 EULA MAE PKWY
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-6406
Practice Address - Country:US
Practice Address - Phone:618-594-8385
Practice Address - Fax:618-594-8601
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist