Provider Demographics
NPI:1881910958
Name:MCDONOUGH, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MCDONOUGH
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 1:66011 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66011 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2002
Practice Address - Country:US
Practice Address - Phone:586-752-6569
Practice Address - Fax:586-752-4781
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302030423OtherREGISTERED PHARMACIST LICENSE