Provider Demographics
NPI:1003490459
Name:GRAHAM, STACY LYNN (CPHT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 N STEPTOE ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7120
Mailing Address - Country:US
Mailing Address - Phone:509-987-4890
Mailing Address - Fax:
Practice Address - Street 1:1901 N STEPTOE ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7120
Practice Address - Country:US
Practice Address - Phone:509-783-3413
Practice Address - Fax:509-735-2802
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60316223183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician