Provider Demographics
NPI:1922584044
Name:HULLER, STEPHANIE DANIELLE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DANIELLE
Last Name:HULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1905
Mailing Address - Country:US
Mailing Address - Phone:618-580-1278
Mailing Address - Fax:
Practice Address - Street 1:5055 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1011
Practice Address - Country:US
Practice Address - Phone:314-771-5314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051298132183500000X
MO2014026379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist