Healthcare Provider Details

I. General information

NPI: 1619291804
Provider Name (Legal Business Name): STACEY LEIGH ENGELBERG PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3663 HILL BLVD JEFFERSON VALLEY PHARMACY
JEFFERSON VALLEY NY
10535
US

IV. Provider business mailing address

3663 HILL BLVD JEFFERSON VALLEY PHARMACY
JEFFERSON VALLEY NY
10535
US

V. Phone/Fax

Practice location:
  • Phone: 914-962-6553
  • Fax: 914-962-6228
Mailing address:
  • Phone: 914-962-6553
  • Fax: 914-962-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number042778
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS28992
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: