Provider Demographics
NPI:1821011727
Name:STACY, JOHN W (PPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:STACY
Suffix:
Gender:M
Credentials:PPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1898 FORT RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-8320
Mailing Address - Country:US
Mailing Address - Phone:307-672-1601
Mailing Address - Fax:307-672-1913
Practice Address - Street 1:1898 FORT RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8320
Practice Address - Country:US
Practice Address - Phone:307-672-1601
Practice Address - Fax:307-672-1913
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH0008038183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist