Provider Demographics
NPI:1477868214
Name:WYATT, STACY (RPH)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WYATT
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 1:3400 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2122
Mailing Address - Country:US
Mailing Address - Phone:318-741-6589
Mailing Address - Fax:318-741-6675
Practice Address - Street 1:3400 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2122
Practice Address - Country:US
Practice Address - Phone:318-741-6589
Practice Address - Fax:318-741-6675
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16748183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist