Provider Demographics
NPI:1962004929
Name:PATILLO, CHRISTINE LYNN
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LYNN
Last Name:PATILLO
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 1:7714 N 800 W
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-9331
Mailing Address - Country:US
Mailing Address - Phone:574-542-2331
Mailing Address - Fax:574-223-3475
Practice Address - Street 1:2395 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-9137
Practice Address - Country:US
Practice Address - Phone:574-223-9482
Practice Address - Fax:574-223-3475
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019000A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist