Provider Demographics
NPI:1356625123
Name:KROTZ, AMBER KRISTEEN
Entity type:Individual
Prefix:DR
First Name:AMBER
Middle Name:KRISTEEN
Last Name:KROTZ
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 1:206 S WALL ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3023
Mailing Address - Country:US
Mailing Address - Phone:618-457-4104
Mailing Address - Fax:618-529-3603
Practice Address - Street 1:206 S WALL ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3023
Practice Address - Country:US
Practice Address - Phone:618-457-4104
Practice Address - Fax:618-529-3603
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist