Provider Demographics
NPI:1508149774
Name:STOVER, LAURA LEE (PHARM D)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:STOVER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1054
Mailing Address - Country:US
Mailing Address - Phone:618-998-1596
Mailing Address - Fax:
Practice Address - Street 1:1710 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1054
Practice Address - Country:US
Practice Address - Phone:618-998-1596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist