Provider Demographics
NPI:1720361488
Name:CHOAT, STACEY L (RPH)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:L
Last Name:CHOAT
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 1:625 ERICA DR
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-6641
Mailing Address - Country:US
Mailing Address - Phone:618-877-6880
Mailing Address - Fax:618-877-2012
Practice Address - Street 1:3732 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3714
Practice Address - Country:US
Practice Address - Phone:618-877-6880
Practice Address - Fax:618-877-2012
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-040811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist