Provider Demographics
NPI:1497036792
Name:BECKMANN, STACEY
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:BECKMANN
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 1:2175 APPLEGATE DR NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-7224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4365 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49534-4544
Practice Address - Country:US
Practice Address - Phone:616-791-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033559183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist