Provider Demographics
NPI:1629613302
Name:THAYER, STACI MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACI
Middle Name:MARIE
Last Name:THAYER
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 1:5125 BROOKSTONE ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5247
Mailing Address - Country:US
Mailing Address - Phone:208-431-7006
Mailing Address - Fax:
Practice Address - Street 1:306 BLUE LAKES BLVD N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4827
Practice Address - Country:US
Practice Address - Phone:208-734-4053
Practice Address - Fax:208-734-4295
Is Sole Proprietor?:No
Enumeration Date:2019-11-17
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8470183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNONEOtherNONE