Healthcare Provider Details

I. General information

NPI: 1528347150
Provider Name (Legal Business Name): PERI STARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2011
Last Update Date: 08/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 WASHINGTON STREET EXT
FAIR HAVEN VT
05743-4402
US

IV. Provider business mailing address

65 HOMESTEAD RD
SARATOGA SPRINGS NY
12866-5806
US

V. Phone/Fax

Practice location:
  • Phone: 802-265-3760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0330078234
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: