MEDICARE: CLARK STILLAHN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	10736	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10736	OTHER	NE	NEBRASKA STATE LICENSE 10736

General Provider Information

NPI Number	:	1962764993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARK STILLAHN

Provider Business Mailing Address
First Line	:	533 S LINCOLN AVE
Second Line	:
City	:	YORK
State	:	NE
Zip	:	68467-4211
Country	:	US
Telephone Number	:	402-362-1280
Fax Number	:	402-362-1355

Provider Business Practice Location Address
First Line	:	533 S LINCOLN AVE
Second Line	:
City	:	YORK
State	:	NE
Zip	:	68467-4211
Country	:	US
Telephone Number	:	402-362-1280
Fax Number	:	402-362-1355

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2012
Last Update Date	:	06/14/2012

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Directions to “ CLARK STILLAHN ” Practice Location

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