Provider Demographics
NPI:1639225105
Name:BLACK, STACIE MICHELLE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:MICHELLE
Last Name:BLACK
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 1:409 MULBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-2307
Mailing Address - Country:US
Mailing Address - Phone:731-645-4423
Mailing Address - Fax:731-645-4399
Practice Address - Street 1:WALGREENS
Practice Address - Street 2:409 MULBERRY AVE
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375
Practice Address - Country:US
Practice Address - Phone:731-645-4423
Practice Address - Fax:731-645-4399
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist