Provider Demographics
NPI:1568926426
Name:PAN, STACEY JANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JANE
Last Name:PAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 COVENTRY CT
Mailing Address - Street 2:
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-3302
Mailing Address - Country:US
Mailing Address - Phone:630-362-2984
Mailing Address - Fax:
Practice Address - Street 1:2211 SANDERS RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-6150
Practice Address - Country:US
Practice Address - Phone:847-559-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62946183500000X
MAPH237704183500000X
IL051301217183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist