Provider Demographics
NPI:1780711028
Name:CROSSETT, RICHARD E (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:E
Last Name:CROSSETT
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 1:22 INDIAN TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-1022
Mailing Address - Country:US
Mailing Address - Phone:309-837-5281
Mailing Address - Fax:
Practice Address - Street 1:118 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2226
Practice Address - Country:US
Practice Address - Phone:309-833-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist