Provider Demographics
NPI:1457136699
Name:CHANDY, STAYCEY SUSAN
Entity Type:Individual
Prefix:
First Name:STAYCEY
Middle Name:SUSAN
Last Name:CHANDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9021 FOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-8611
Mailing Address - Country:US
Mailing Address - Phone:405-826-2833
Mailing Address - Fax:
Practice Address - Street 1:4100 DALE EARNHARDT WAY STE 200
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76262-2389
Practice Address - Country:US
Practice Address - Phone:405-826-2833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist