MEDICARE: DR. MARCUS M STAVCHANSKY PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	39396	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39396	OTHER	TX	PHARMACY LICENSE

General Provider Information

NPI Number	:	1073654661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCUS M STAVCHANSKY PHARM.D.

Provider Business Mailing Address
First Line	:	4604 BRETTON BAY LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-6803
Country	:	US
Telephone Number	:	512-797-6470
Fax Number	:

Provider Business Practice Location Address
First Line	:	1341 W MOCKINGBIRD LN
Second Line	:	SUITE #400 E
City	:	DALLAS
State	:	TX
Zip	:	75247-6913
Country	:	US
Telephone Number	:	214-647-9312
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	07/11/2012

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