Basic Information
| Provider Information | |||||||||
| NPI: | 1649314931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTY | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.PH. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.PH. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610681717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155622181 | ||||||||
| FaxNumber: | 8155612772 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610681717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155622181 | ||||||||
| FaxNumber: | 8155612772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 1-13948 | KS | N | Pharmacy Service Providers | Pharmacist | 183500000X | 051-287218 | IL | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.