Provider Demographics
NPI:1922345743
Name:MARKHAM, MARY STACIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:STACIE
Last Name:MARKHAM
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 1:10400 SW VILLAGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2186
Mailing Address - Country:US
Mailing Address - Phone:772-345-9911
Mailing Address - Fax:772-345-9910
Practice Address - Street 1:10400 SW VILLAGE CENTER DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2186
Practice Address - Country:US
Practice Address - Phone:772-345-9911
Practice Address - Fax:772-345-9910
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40741183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist