Healthcare Provider Details

I. General information

NPI: 1407796667
Provider Name (Legal Business Name): STACIA HUMPHREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6905 KENNEDY AVE
HAMMOND IN
46323-2210
US

IV. Provider business mailing address

6905 KENNEDY AVE
HAMMOND IN
46323-2210
US

V. Phone/Fax

Practice location:
  • Phone: 219-844-5034
  • Fax:
Mailing address:
  • Phone: 219-844-5034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26031785A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: