Provider Demographics
NPI:1669759734
Name:BOCK, STACY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:BOCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 RIVER WALK MALL
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1026
Mailing Address - Country:US
Mailing Address - Phone:304-744-5128
Mailing Address - Fax:304-744-9522
Practice Address - Street 1:5 RIVER WALK MALL
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1026
Practice Address - Country:US
Practice Address - Phone:304-744-5128
Practice Address - Fax:304-744-9522
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007750183500000X
OH03227959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist