Provider Demographics
NPI:1275134322
Name:VISOCKIS, STACEY LYNN
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:VISOCKIS
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 1:3827 SUMMIT VIEW DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2030
Mailing Address - Country:US
Mailing Address - Phone:616-723-5642
Mailing Address - Fax:
Practice Address - Street 1:3999 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-8350
Practice Address - Country:US
Practice Address - Phone:616-784-1619
Practice Address - Fax:616-784-2454
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315109441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist