Provider Demographics
NPI:1073654661
Name:STAVCHANSKY, MARCUS M (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:M
Last Name:STAVCHANSKY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 BRETTON BAY LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6803
Mailing Address - Country:US
Mailing Address - Phone:512-797-6470
Mailing Address - Fax:
Practice Address - Street 1:1341 W MOCKINGBIRD LN
Practice Address - Street 2:SUITE #400 E
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-6913
Practice Address - Country:US
Practice Address - Phone:214-647-9312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX39396OtherPHARMACY LICENSE