Provider Demographics
NPI:1568784494
Name:GIRARDEAU, STACEY GLENN (RPH)
Entity Type:Individual
Prefix:MR
First Name:STACEY
Middle Name:GLENN
Last Name:GIRARDEAU
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 BRANNEN ST STE B
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5184
Mailing Address - Country:US
Mailing Address - Phone:912-225-9279
Mailing Address - Fax:912-225-9284
Practice Address - Street 1:606 BRANNEN ST STE B
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5184
Practice Address - Country:US
Practice Address - Phone:912-225-9279
Practice Address - Fax:912-225-9284
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist