Basic Information
Provider Information | |||||||||
NPI: | 1215195524 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMPSON | ||||||||
FirstName: | STACEY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARM.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THOMPSON | ||||||||
OtherFirstName: | STACEY | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHARM.D | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 516 NIZHONI BLVD | ||||||||
Address2: | BOX 1337 | ||||||||
City: | GALLUP | ||||||||
State: | NM | ||||||||
PostalCode: | 873015748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5057221185 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 516 NIZHONI BLVD | ||||||||
Address2: | BOX 1337 | ||||||||
City: | GALLUP | ||||||||
State: | NM | ||||||||
PostalCode: | 873015748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5057221185 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2008 | ||||||||
LastUpdateDate: | 05/23/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RP00006845 | NM | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.