Provider Demographics
NPI:1144322074
Name:DEWALD, STACEY L (RPH)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:L
Last Name:DEWALD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 PIMLICO LN
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-6185
Mailing Address - Country:US
Mailing Address - Phone:989-790-8093
Mailing Address - Fax:
Practice Address - Street 1:1500 WEISS ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5251
Practice Address - Country:US
Practice Address - Phone:989-497-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist