Provider Demographics
NPI:1932354610
Name:KROETSCH, MARK (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KROETSCH
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 1:1500 BROOKS AVE
Mailing Address - Street 2:ATTN: PHARMACY OFFICE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3512
Mailing Address - Country:US
Mailing Address - Phone:585-279-4355
Mailing Address - Fax:585-239-2015
Practice Address - Street 1:601 AMHERST ST
Practice Address - Street 2:ATTN: PHARMACY MANAGER
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-2901
Practice Address - Country:US
Practice Address - Phone:716-877-1477
Practice Address - Fax:716-877-2331
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY034153OtherPHARMACIST LICENSE