Provider Demographics
NPI:1710581228
Name:KRIVI, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:KRIVI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:TESDAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:218 HARTMAN RD
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-4118
Mailing Address - Country:US
Mailing Address - Phone:815-674-4175
Mailing Address - Fax:
Practice Address - Street 1:2001 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4628
Practice Address - Country:US
Practice Address - Phone:217-546-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051298616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist