Healthcare Provider Details

I. General information

NPI: 1043123649
Provider Name (Legal Business Name): MIRANDA REED LANE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12866 TROXLER AVE
HIGHLAND IL
62249-2806
US

IV. Provider business mailing address

16652 PEMBROOKE CT
CARLYLE IL
62231-2405
US

V. Phone/Fax

Practice location:
  • Phone: 618-651-2939
  • Fax:
Mailing address:
  • Phone: 618-610-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.305948
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: