Provider Demographics
NPI:1508063249
Name:GALLENTINE, STACIE MARIE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:MARIE
Last Name:GALLENTINE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8809 32ND CT N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2456
Mailing Address - Country:US
Mailing Address - Phone:612-396-4257
Mailing Address - Fax:
Practice Address - Street 1:9655 COLORADO LN N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445
Practice Address - Country:US
Practice Address - Phone:763-315-0737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118193183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN118193OtherPHARMACIST LICENSE