Provider Demographics
NPI:1104016500
Name:HAMPTON, STACY R (PHARMD, PA-C)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:R
Last Name:HAMPTON
Suffix:
Gender:F
Credentials:PHARMD, PA-C
Other - Prefix:MS
Other - First Name:ANASTASIA
Other - Middle Name:R
Other - Last Name:HAMPTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4524
Practice Address - Street 1:16869 65TH AVE # 287
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7865
Practice Address - Country:US
Practice Address - Phone:541-808-1093
Practice Address - Fax:541-738-2106
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA152548363A00000X
OR101151835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930635514OtherNBMC GROUP TAX ID
OR500625975Medicaid
OR1407812365OtherNBMC GROUP NPI
ORMD19773OtherSUPERVISING PHYSICIAN LICENSE
OR161133OtherNBMC GROUP MEDICAID
ORR0000WFBTVOtherNBMC GROUP MEDICARE