Provider Demographics
NPI:1346517356
Name:DOOLEY, LACEY M (RPH)
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:M
Last Name:DOOLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:LACEY
Other - Middle Name:M
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:232 SHIRLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701
Mailing Address - Country:US
Mailing Address - Phone:573-332-0329
Mailing Address - Fax:573-332-0422
Practice Address - Street 1:401 BELT LINE RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4406
Practice Address - Country:US
Practice Address - Phone:618-344-6639
Practice Address - Fax:618-344-6041
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290110183500000X
MO2003018316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist