Provider Demographics
NPI:1215035118
Name:MARTIN, STACY LYNN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 E KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5124
Mailing Address - Country:US
Mailing Address - Phone:704-374-9708
Mailing Address - Fax:
Practice Address - Street 1:1801 ROZZELLES FERRY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-4228
Practice Address - Country:US
Practice Address - Phone:704-350-1086
Practice Address - Fax:704-350-1283
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist