Provider Demographics
NPI:1902132756
Name:STACY, JOHN N (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:N
Last Name:STACY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5009
Mailing Address - Country:US
Mailing Address - Phone:828-264-3055
Mailing Address - Fax:828-264-3053
Practice Address - Street 1:345 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5009
Practice Address - Country:US
Practice Address - Phone:828-264-3055
Practice Address - Fax:828-264-3053
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5355OtherPHARMACIST