Provider Demographics
NPI:1710114038
Name:ANDERSON, STACY
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2139
Mailing Address - Country:US
Mailing Address - Phone:970-243-3411
Mailing Address - Fax:866-491-5888
Practice Address - Street 1:1401 N 1ST ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2139
Practice Address - Country:US
Practice Address - Phone:970-243-3411
Practice Address - Fax:866-491-5888
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA10003721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPHA0021987OtherPHARMACIST LICENSE