Provider Demographics
NPI:1659433381
Name:STOUT, BRUCE ALLEN (RPH)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:STOUT
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 1:13135 MESSMER RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNA
Mailing Address - State:IL
Mailing Address - Zip Code:61074-8565
Mailing Address - Country:US
Mailing Address - Phone:815-273-4344
Mailing Address - Fax:
Practice Address - Street 1:217 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:SAVANNA
Practice Address - State:IL
Practice Address - Zip Code:61074-1917
Practice Address - Country:US
Practice Address - Phone:815-273-2713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist