Healthcare Provider Details

I. General information

NPI: 1629644711
Provider Name (Legal Business Name): CHRIS STIPHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2021
Last Update Date: 05/31/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

IV. Provider business mailing address

PO BOX 683
BLOOMINGTON IL
61702-0683
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-5190
  • Fax:
Mailing address:
  • Phone: 309-684-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049.174199
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: