Provider Demographics
NPI:1811273543
Name:GORSKI, STACY LYNN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:GORSKI
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 1:43168 HANFORD RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3336
Mailing Address - Country:US
Mailing Address - Phone:734-612-7218
Mailing Address - Fax:
Practice Address - Street 1:7210 N MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2502
Practice Address - Country:US
Practice Address - Phone:734-427-5958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032689183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist