Provider Demographics
NPI:1073944484
Name:STACEY, RICHARD JOSEPH JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:STACEY
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15753 BARLETTA DR
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6003
Mailing Address - Country:US
Mailing Address - Phone:626-587-6639
Mailing Address - Fax:
Practice Address - Street 1:15753 BARLETTA DR
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6003
Practice Address - Country:US
Practice Address - Phone:626-587-6639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist