Provider Demographics
NPI:1962659664
Name:THACKER, STACEY M (PHARM D)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:THACKER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 UNIVERSITY PARK DR
Mailing Address - Street 2:CAMPUS BOX 2000
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62026-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 UNIVERSITY PARK DR
Practice Address - Street 2:CAMPUS BOX 2000
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-0001
Practice Address - Country:US
Practice Address - Phone:618-650-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292099261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care