Provider Demographics
NPI:1356627327
Name:DALTON, STACEY DEBRA (PHARMD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DEBRA
Last Name:DALTON
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 1:4005 HIGH RESORT BLVD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-5906
Mailing Address - Country:US
Mailing Address - Phone:505-253-6000
Mailing Address - Fax:505-253-8619
Practice Address - Street 1:4005 HIGH RESORT BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5906
Practice Address - Country:US
Practice Address - Phone:505-253-6000
Practice Address - Fax:505-253-8619
Is Sole Proprietor?:No
Enumeration Date:2011-10-22
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007514183500000X
NMPC00000270183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist