Provider Demographics
NPI:1942828512
Name:CHAO, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:CHAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4446 HENDRICKS AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6369
Mailing Address - Country:US
Mailing Address - Phone:904-551-5094
Mailing Address - Fax:904-527-1244
Practice Address - Street 1:3851 EMERSON ST STE 13
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4756
Practice Address - Country:US
Practice Address - Phone:904-551-5094
Practice Address - Fax:904-527-1244
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist