Provider Demographics
NPI:1356704514
Name:CROCE, MARK
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:CROCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTED
Mailing Address - State:CT
Mailing Address - Zip Code:06098-1703
Mailing Address - Country:US
Mailing Address - Phone:860-738-6250
Mailing Address - Fax:860-738-6255
Practice Address - Street 1:47 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINSTED
Practice Address - State:CT
Practice Address - Zip Code:06098-1703
Practice Address - Country:US
Practice Address - Phone:860-738-6250
Practice Address - Fax:860-738-6255
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist