Provider Demographics
NPI:1467054056
Name:CALVERT, STACEY LANE (RPH)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LANE
Last Name:CALVERT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15150 US HIGHWAY 150
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-6615
Mailing Address - Country:US
Mailing Address - Phone:217-466-5818
Mailing Address - Fax:
Practice Address - Street 1:15150 US HIGHWAY 150
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-6615
Practice Address - Country:US
Practice Address - Phone:217-466-5818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist