Healthcare Provider Details

I. General information

NPI: 1003531310
Provider Name (Legal Business Name): LUCAS B STOLLER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 10/10/2022
Certification Date: 10/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-588-6402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License Number051294213
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: