Provider Demographics
NPI:1861089211
Name:PRUETT, STEPHANIE (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PRUETT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W EDWARDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 W EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1261
Practice Address - Country:US
Practice Address - Phone:618-254-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015028995183500000X
IL051298917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist