Healthcare Provider Details

I. General information

NPI: 1073924445
Provider Name (Legal Business Name): STACEY HUDSON PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9920 BUSTLETON AVE
PHILADELPHIA PA
19115-2149
US

IV. Provider business mailing address

9920 BUSTLETON AVE
PHILADELPHIA PA
19115-2149
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-1177
  • Fax: 215-464-4953
Mailing address:
  • Phone: 215-464-1177
  • Fax: 215-464-4953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP446176
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: