Provider Demographics
NPI:1184062010
Name:RIDER, STACEY DANIELLE (PHARMD, LDE)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:DANIELLE
Last Name:RIDER
Suffix:
Gender:F
Credentials:PHARMD, LDE
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:DANIELLE
Other - Last Name:GASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:464 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-1882
Mailing Address - Country:US
Mailing Address - Phone:859-733-4827
Mailing Address - Fax:859-733-4825
Practice Address - Street 1:464 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-1882
Practice Address - Country:US
Practice Address - Phone:859-733-4827
Practice Address - Fax:859-733-4825
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016437183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY126551OtherLICENSED DIABETES EDUCATOR