Provider Demographics
NPI:1407143225
Name:O'MALLEY, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:O'MALLEY
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 1:7900 32ND ST N
Mailing Address - Street 2:T2135
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-4054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7900 32ND ST N
Practice Address - Street 2:T2135
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-4054
Practice Address - Country:US
Practice Address - Phone:651-855-0991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119814183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist