Provider Demographics
NPI:1720491426
Name:NISCH, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:NISCH
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 1:955 S SPRINGFIELD AVE UNIT C216
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3571
Mailing Address - Country:US
Mailing Address - Phone:908-514-9482
Mailing Address - Fax:
Practice Address - Street 1:11 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930-2407
Practice Address - Country:US
Practice Address - Phone:908-879-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02743400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist