Healthcare Provider Details

I. General information

NPI: 1184446841
Provider Name (Legal Business Name): ANDREA STAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 W HIGHWAY 50
O FALLON IL
62269-1615
US

IV. Provider business mailing address

820 CARDIFF CT
O FALLON IL
62269-6878
US

V. Phone/Fax

Practice location:
  • Phone: 618-622-0507
  • Fax:
Mailing address:
  • Phone: 812-251-7266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051305766
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: