Provider Demographics
NPI:1295191419
Name:STACKO, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:STACKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46440 US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:OBERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44074-9475
Mailing Address - Country:US
Mailing Address - Phone:440-774-6734
Mailing Address - Fax:
Practice Address - Street 1:46440 US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-9475
Practice Address - Country:US
Practice Address - Phone:440-774-6734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03234267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist