Provider Demographics
NPI:1710263223
Name:OSMUN, STACY LANE (RPH)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:LANE
Last Name:OSMUN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-3500
Mailing Address - Country:US
Mailing Address - Phone:303-908-4764
Mailing Address - Fax:
Practice Address - Street 1:316 W ASPEN AVE
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2504
Practice Address - Country:US
Practice Address - Phone:970-858-0147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13417183500000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist