Provider Demographics
NPI:1003141631
Name:STILTNER, JACKIE LEE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LEE
Last Name:STILTNER
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 1:13685 GRAPEVINE RD
Mailing Address - Street 2:
Mailing Address - City:PHYLLIS
Mailing Address - State:KY
Mailing Address - Zip Code:41554-8504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11349 STATE HWY 1056 BUSKIRK PLAZA
Practice Address - Street 2:RITE AID
Practice Address - City:MCCARR
Practice Address - State:KY
Practice Address - Zip Code:41544
Practice Address - Country:US
Practice Address - Phone:606-427-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY014680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist