Provider Demographics
NPI:1164024790
Name:CLACK, STEPHANIE LEE (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LEE
Last Name:CLACK
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E ASH ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-4100
Mailing Address - Country:US
Mailing Address - Phone:937-615-9968
Mailing Address - Fax:937-615-9972
Practice Address - Street 1:1300 E ASH ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-4100
Practice Address - Country:US
Practice Address - Phone:937-615-9968
Practice Address - Fax:937-615-9972
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03326853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist