Provider Demographics
NPI:1467729103
Name:STARK, TALLY SHANNON (RP)
Entity Type:Individual
Prefix:MRS
First Name:TALLY
Middle Name:SHANNON
Last Name:STARK
Suffix:
Gender:F
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-2661
Mailing Address - Country:US
Mailing Address - Phone:402-494-8827
Mailing Address - Fax:
Practice Address - Street 1:1030 W 21ST ST
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-2661
Practice Address - Country:US
Practice Address - Phone:402-494-8827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist