Provider Demographics
NPI:1881071918
Name:TACKETT, STACI LYNN (PHARM D)
Entity type:Individual
Prefix:DR
First Name:STACI
Middle Name:LYNN
Last Name:TACKETT
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3234
Mailing Address - Country:US
Mailing Address - Phone:918-453-5655
Mailing Address - Fax:918-431-4148
Practice Address - Street 1:1500 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3234
Practice Address - Country:US
Practice Address - Phone:918-453-5655
Practice Address - Fax:918-431-4148
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist