MEDICARE: MS. STACY R. HAMPTON PHARM.D., PA-C

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	363A00000X	Physician Assistant	PA152548	OR
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	10115	OR

General Provider Information

NPI Number	:	1104016500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACY R. HAMPTON PHARM.D., PA-C

Provider Business Mailing Address
First Line	:	1900 WOODLAND DR
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2045
Country	:	US
Telephone Number	:	541-267-5151
Fax Number	:	541-266-4524

Provider Business Practice Location Address
First Line	:	16869 65TH AVE # 287
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-7865
Country	:	US
Telephone Number	:	541-808-1093
Fax Number	:	541-738-2106

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

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	02/02/2016

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