Provider Demographics
NPI:1730583501
Name:SMITH, STACY LYNN
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0955
Mailing Address - Country:US
Mailing Address - Phone:435-313-9114
Mailing Address - Fax:928-645-0225
Practice Address - Street 1:1017 W HAUL RD
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0656
Practice Address - Country:US
Practice Address - Phone:435-313-9114
Practice Address - Fax:928-645-0225
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016867183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist