Provider Demographics
NPI:1063503274
Name:STACKS, EMILY A
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:A
Last Name:STACKS
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 1:503 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-6006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-6006
Practice Address - Country:US
Practice Address - Phone:803-283-0870
Practice Address - Fax:803-283-3387
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132476741Medicaid
SCDM0797Medicaid
SCDM0797Medicaid