Provider Demographics
NPI:1801496690
Name:FOOTE, CRYSTAL ANN (RPH)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:FOOTE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 NAPLES DR
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-2443
Mailing Address - Country:US
Mailing Address - Phone:219-322-4293
Mailing Address - Fax:
Practice Address - Street 1:1555 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1317
Practice Address - Country:US
Practice Address - Phone:219-865-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.039199183500000X
IN26017341A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist