Basic Information
| Provider Information | |||||||||
| NPI: | 1013539683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PHARMD, MHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 S POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | MANTENO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609501693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037801166 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159357256 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2020 | ||||||||
| LastUpdateDate: | 05/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 9232 | OR | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.