Provider Demographics
NPI:1881466522
Name:KACZOROWSKI, STACEY MICHELLE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:KACZOROWSKI
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 1:7786 WELLSBURY DR
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1702
Mailing Address - Country:US
Mailing Address - Phone:567-213-1879
Mailing Address - Fax:
Practice Address - Street 1:345 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1806
Practice Address - Country:US
Practice Address - Phone:419-562-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03127759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist