Provider Demographics
NPI:1578849535
Name:BATES, STACY LOUISEB (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LOUISEB
Last Name:BATES
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 1:6390 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2600
Mailing Address - Country:US
Mailing Address - Phone:763-585-9946
Mailing Address - Fax:763-585-9418
Practice Address - Street 1:6390 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2600
Practice Address - Country:US
Practice Address - Phone:763-585-9946
Practice Address - Fax:763-569-9904
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119993183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2422323Medicaid