Provider Demographics
NPI:1407282049
Name:GILL, STACEY E (RPH)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:E
Last Name:GILL
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 1:13335 DIEGEL DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-1357
Mailing Address - Country:US
Mailing Address - Phone:586-677-6586
Mailing Address - Fax:
Practice Address - Street 1:30550 STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:MADISON HTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1611
Practice Address - Country:US
Practice Address - Phone:246-616-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-15
Last Update Date:2013-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302410472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist