Provider Demographics
NPI:1124396494
Name:MITCHELL, STEPHEN EARL
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:EARL
Last Name:MITCHELL
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 1:625 W PERSHING RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1632
Mailing Address - Country:US
Mailing Address - Phone:217-875-2751
Mailing Address - Fax:217-875-6631
Practice Address - Street 1:625 W PERSHING RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1632
Practice Address - Country:US
Practice Address - Phone:217-875-2751
Practice Address - Fax:217-875-6631
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.026337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist