Provider Demographics
NPI:1558684852
Name:BANTA, STACEY M
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:BANTA
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 1:4945 TINDERBOX CIR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2131
Mailing Address - Country:US
Mailing Address - Phone:315-699-0812
Mailing Address - Fax:315-699-0818
Practice Address - Street 1:6189 ROUTE 31
Practice Address - Street 2:WALGREENS PHARMACY
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039
Practice Address - Country:US
Practice Address - Phone:315-699-0812
Practice Address - Fax:315-699-0818
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051406183500000X
MAPH21046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist