Provider Demographics
NPI:1609144948
Name:FEDERMAN, STACEY M (PHARM D)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:FEDERMAN
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 1:2800 DUBLIN BLVD
Mailing Address - Street 2:T2771
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568
Mailing Address - Country:US
Mailing Address - Phone:925-241-1043
Mailing Address - Fax:925-241-1053
Practice Address - Street 1:2800 DUBLIN BLVD
Practice Address - Street 2:T2771
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568
Practice Address - Country:US
Practice Address - Phone:925-241-1043
Practice Address - Fax:925-241-1053
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist