Healthcare Provider Details

I. General information

NPI: 1902183411
Provider Name (Legal Business Name): STACEY MADER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2011
Last Update Date: 11/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CLYDESDALE TRL
MEDINA MN
55340-4538
US

IV. Provider business mailing address

6649 SHADYVIEW LN N
MAPLE GROVE MN
55311-4588
US

V. Phone/Fax

Practice location:
  • Phone: 763-852-0007
  • Fax:
Mailing address:
  • Phone: 763-229-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number119094
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-13053
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: