Provider Demographics
NPI:1275122731
Name:LEDBETTER, STEPHEN L (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:L
Last Name:LEDBETTER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2108
Mailing Address - Country:US
Mailing Address - Phone:618-252-5349
Mailing Address - Fax:618-252-1395
Practice Address - Street 1:304 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2108
Practice Address - Country:US
Practice Address - Phone:618-252-5349
Practice Address - Fax:618-252-1395
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.030039183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3711242590503Medicaid