Provider Demographics
NPI:1225658636
Name:MCDONALD, STACEY LYNN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LYNN
Last Name:MCDONALD
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 1:3480 WHITE DOVE LN
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-6860
Mailing Address - Country:US
Mailing Address - Phone:262-490-3684
Mailing Address - Fax:
Practice Address - Street 1:1561 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2215
Practice Address - Country:US
Practice Address - Phone:920-497-5959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0019174183500000X
WI16488-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist