Provider Demographics
NPI:1720680184
Name:BOWER, STACIE JO
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:JO
Last Name:BOWER
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 1:24 RISING SUN TOWN CTR
Mailing Address - Street 2:
Mailing Address - City:RISING SUN
Mailing Address - State:MD
Mailing Address - Zip Code:21911-1902
Mailing Address - Country:US
Mailing Address - Phone:410-658-8253
Mailing Address - Fax:844-411-6809
Practice Address - Street 1:24 RISING SUN TOWN CTR
Practice Address - Street 2:
Practice Address - City:RISING SUN
Practice Address - State:MD
Practice Address - Zip Code:21911-1902
Practice Address - Country:US
Practice Address - Phone:410-658-8253
Practice Address - Fax:844-411-6809
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist