Provider Demographics
NPI:1073399416
Name:STALEY, AUTUMN LEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:LEE
Last Name:STALEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PROFESSIONAL PL
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-4599
Mailing Address - Country:US
Mailing Address - Phone:681-456-6195
Mailing Address - Fax:
Practice Address - Street 1:120 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-4599
Practice Address - Country:US
Practice Address - Phone:681-456-6195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0013756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist