Provider Demographics
NPI:1164754040
Name:PECORA, STACEY M (RPH)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:PECORA
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 1:25 WEDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:PORTER CORNERS
Mailing Address - State:NY
Mailing Address - Zip Code:12859-1749
Mailing Address - Country:US
Mailing Address - Phone:518-893-6113
Mailing Address - Fax:
Practice Address - Street 1:100 SARATOGA VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-3737
Practice Address - Country:US
Practice Address - Phone:518-899-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist