1639225105 NPI number — DR. STACIE MICHELLE BLACK PHARM D

Table of content: DR. STACIE MICHELLE BLACK PHARM D (NPI 1639225105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639225105 NPI number — DR. STACIE MICHELLE BLACK PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
STACIE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639225105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
409 MULBERRY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SELMER
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38375-2307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-645-4423
Provider Business Mailing Address Fax Number:
731-645-4399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WALGREENS
Provider Second Line Business Practice Location Address:
409 MULBERRY AVE
Provider Business Practice Location Address City Name:
SELMER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-645-4423
Provider Business Practice Location Address Fax Number:
731-645-4399
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  13036 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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