Provider Demographics
NPI:1801164322
Name:FECKLER, STACY MARIE (PHARM D)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:FECKLER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 S SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2080
Mailing Address - Country:US
Mailing Address - Phone:815-485-7294
Mailing Address - Fax:815-485-7326
Practice Address - Street 1:450 S SCHOOLHOUSE RD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2080
Practice Address - Country:US
Practice Address - Phone:815-485-7294
Practice Address - Fax:815-485-7326
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.288352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361924025180Medicaid