Provider Demographics
NPI:1689269219
Name:STACY, SAMANTHA JO (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:STACY
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 1:1175 S COLLEGE MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6290
Mailing Address - Country:US
Mailing Address - Phone:812-333-5760
Mailing Address - Fax:
Practice Address - Street 1:1175 S COLLEGE MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6290
Practice Address - Country:US
Practice Address - Phone:812-333-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029142A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist