Provider Demographics
NPI:1518635366
Name:TROUT, CAROLYN ELYCE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ELYCE
Last Name:TROUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 E CLEAR LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3216 E CLEAR LAKE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6208
Practice Address - Country:US
Practice Address - Phone:217-544-7948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-04
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.304261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist