Provider Demographics
NPI:1740208784
Name:HAAS, LUANN
Entity type:Individual
Prefix:
First Name:LUANN
Middle Name:
Last Name:HAAS
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:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:NAUVOO
Mailing Address - State:IL
Mailing Address - Zip Code:62354-0248
Mailing Address - Country:US
Mailing Address - Phone:217-453-2717
Mailing Address - Fax:217-453-6456
Practice Address - Street 1:1350 MULHOLLAND
Practice Address - Street 2:
Practice Address - City:NAUVOO
Practice Address - State:IL
Practice Address - Zip Code:62354-0248
Practice Address - Country:US
Practice Address - Phone:217-453-2717
Practice Address - Fax:217-453-6456
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3711031796235401Medicaid
IL3711031796235401Medicaid