Provider Demographics
NPI:1578094439
Name:HERSRUD, STACY LYNN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNN
Last Name:HERSRUD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3749
Mailing Address - Country:US
Mailing Address - Phone:701-232-4872
Mailing Address - Fax:
Practice Address - Street 1:2425 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3749
Practice Address - Country:US
Practice Address - Phone:701-232-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist