Provider Demographics
NPI:1013290717
Name:MOHN, STACEY L (RPH)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:L
Last Name:MOHN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8728
Mailing Address - Country:US
Mailing Address - Phone:636-329-9163
Mailing Address - Fax:636-329-9605
Practice Address - Street 1:4650 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8728
Practice Address - Country:US
Practice Address - Phone:636-329-9163
Practice Address - Fax:636-329-9605
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist