Provider Demographics
NPI:1902183411
Name:MADER, STACEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MADER
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 1:6649 SHADYVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4588
Mailing Address - Country:US
Mailing Address - Phone:763-229-0940
Mailing Address - Fax:
Practice Address - Street 1:300 CLYDESDALE TRL
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:MN
Practice Address - Zip Code:55340-4538
Practice Address - Country:US
Practice Address - Phone:763-852-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119094183500000X
KS1-13053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist