Provider Demographics
NPI:1376884403
Name:BOSCH, STACY (RPH)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BOSCH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 W PINE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-9331
Mailing Address - Country:US
Mailing Address - Phone:231-652-9484
Mailing Address - Fax:231-652-9485
Practice Address - Street 1:91 W PINE LAKE DR
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337-9331
Practice Address - Country:US
Practice Address - Phone:231-652-9484
Practice Address - Fax:231-652-9485
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302030949OtherREGISTERED PHARMACIST PERMANENT I.D. NUMBER