Healthcare Provider Details

I. General information

NPI: 1417939919
Provider Name (Legal Business Name): STACI M. BALOG R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 HULTON RD
OAKMONT PA
15139-1135
US

IV. Provider business mailing address

209 ALTERMOOR DR
NATRONA HEIGHTS PA
15065-9724
US

V. Phone/Fax

Practice location:
  • Phone: 412-826-6032
  • Fax:
Mailing address:
  • Phone: 724-295-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP040576L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: