Provider Demographics
NPI:1972089852
Name:STACH, CARMEN MARIE
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:MARIE
Last Name:STACH
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 1:4050 W PINE BLVD APT 3205
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3349
Mailing Address - Country:US
Mailing Address - Phone:763-276-6759
Mailing Address - Fax:
Practice Address - Street 1:4050 W PINE BLVD
Practice Address - Street 2:APT 3205
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-6313
Practice Address - Country:US
Practice Address - Phone:763-276-6759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017028106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist