=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124319884
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY VALENCIA SAMUEL PHARM D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2011
-----------------------------------------------------
Last Update Date | 04/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4305 NC HIGHWAY 49
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-454-5920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11215 GOLD PAN RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-8622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-502-8052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 15673
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------