Provider Demographics
NPI:1336881002
Name:ANDERSON, STACI (PHARMD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:MILNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:161 HUNTERS RDG
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8132
Mailing Address - Country:US
Mailing Address - Phone:770-597-8445
Mailing Address - Fax:
Practice Address - Street 1:310 W 5TH ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1102
Practice Address - Country:US
Practice Address - Phone:270-527-3597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015563183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist