Provider Demographics
NPI:1306373782
Name:BANE, STACEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BANE
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 1:9902 MISTY LAYNE
Mailing Address - Street 2:
Mailing Address - City:HAUBSTADT
Mailing Address - State:IN
Mailing Address - Zip Code:47639
Mailing Address - Country:US
Mailing Address - Phone:812-779-6574
Mailing Address - Fax:
Practice Address - Street 1:415 MULBERRY STREET
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713
Practice Address - Country:US
Practice Address - Phone:812-422-3448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021707A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist