Provider Demographics
NPI:1326284522
Name:TAM, STACY DIANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:DIANE
Last Name:TAM
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 1:1253 OAKHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2457
Mailing Address - Country:US
Mailing Address - Phone:626-357-1928
Mailing Address - Fax:
Practice Address - Street 1:1515 N VERMONT AVE
Practice Address - Street 2:PHARMACY OPERATIONS SUITE 237
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5337
Practice Address - Country:US
Practice Address - Phone:323-783-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist