Provider Demographics
NPI:1275083743
Name:PHILIP, STACEY MARIAM
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIAM
Last Name:PHILIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 WELSH RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-3238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2503 WELSH RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-3238
Practice Address - Country:US
Practice Address - Phone:215-671-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-09
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP451116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist