Provider Demographics
NPI:1881011716
Name:SMITH, STACEY AMANDA (PHARMD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:AMANDA
Last Name:SMITH
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 1:4468 EAGLE RIVER RUN
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-8753
Mailing Address - Country:US
Mailing Address - Phone:303-438-6890
Mailing Address - Fax:
Practice Address - Street 1:4468 EAGLE RIVER RUN
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-8753
Practice Address - Country:US
Practice Address - Phone:303-438-6890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist