Provider Demographics
NPI:1700163847
Name:STALEY, STEVEN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:STALEY
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1006
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-1006
Mailing Address - Country:US
Mailing Address - Phone:307-883-4600
Mailing Address - Fax:
Practice Address - Street 1:190 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-4600
Practice Address - Fax:
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
WY2643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist