Basic Information
Provider Information
NPI: 1003141631
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: STILTNER
FirstName: JACKIE
MiddleName: LEE
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 13685 GRAPEVINE RD
Address2:  
City: PHYLLIS
State: KY
PostalCode: 415548504
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 11349 STATE HWY 1056 BUSKIRK PLAZA
Address2: RITE AID
City: MCCARR
State: KY
PostalCode: 41544
CountryCode: US
TelephoneNumber: 6064279007
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/15/2009
LastUpdateDate: 10/15/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X014680KYY Pharmacy Service ProvidersPharmacist 

No ID Information.


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