Provider Demographics
NPI:1417765769
Name:COLLINS, KRYSTAN
Entity type:Individual
Prefix:
First Name:KRYSTAN
Middle Name:
Last Name:COLLINS
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 1:647 TROY RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-5566
Mailing Address - Country:US
Mailing Address - Phone:618-741-0670
Mailing Address - Fax:
Practice Address - Street 1:3400 GREEN MOUNT CROSSING DR
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7277
Practice Address - Country:US
Practice Address - Phone:618-628-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.306824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist