Provider Demographics
NPI:1376170951
Name:BEISE, STACEY LEIGH
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEIGH
Last Name:BEISE
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 1:121 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:16134-9117
Mailing Address - Country:US
Mailing Address - Phone:724-932-5355
Mailing Address - Fax:724-932-3943
Practice Address - Street 1:121 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:PA
Practice Address - Zip Code:16134-9117
Practice Address - Country:US
Practice Address - Phone:724-932-5355
Practice Address - Fax:724-932-3943
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP0435464L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist