Provider Demographics
NPI:1336749944
Name:CAVANAUGH, STACY MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:ROSARIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1840 S BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-3883
Mailing Address - Country:US
Mailing Address - Phone:856-629-1024
Mailing Address - Fax:
Practice Address - Street 1:1840 S BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-3883
Practice Address - Country:US
Practice Address - Phone:856-629-1024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02559200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist