Provider Demographics
NPI:1124197611
Name:UGANSKI, STACEY L (RPH)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:UGANSKI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 GLEN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-3508
Mailing Address - Country:US
Mailing Address - Phone:231-744-5173
Mailing Address - Fax:
Practice Address - Street 1:101 W COLBY ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1014
Practice Address - Country:US
Practice Address - Phone:231-893-5495
Practice Address - Fax:231-893-2723
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302028520OtherPHARMACIST LICENSE NUMBER