Provider Demographics
NPI:1689836405
Name:NORMAN, STACI-MARIE BALOG (PHARMD, CDE)
Entity Type:Individual
Prefix:DR
First Name:STACI-MARIE
Middle Name:BALOG
Last Name:NORMAN
Suffix:
Gender:F
Credentials:PHARMD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 WEST COTTER STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46613
Mailing Address - Country:US
Mailing Address - Phone:574-993-1737
Mailing Address - Fax:574-251-2446
Practice Address - Street 1:760 WEST COTTER STREET
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46613
Practice Address - Country:US
Practice Address - Phone:574-993-1737
Practice Address - Fax:574-251-2446
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018206A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist