MEDICARE: STACIA STULTS

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	26018348A	IN

General Provider Information

NPI Number	:	1780220277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIA STULTS

Provider Business Mailing Address
First Line	:	209 CHICAGO AVE
Second Line	:
City	:	GOSHEN
State	:	IN
Zip	:	46526-2311
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	209 CHICAGO AVE
Second Line	:
City	:	GOSHEN
State	:	IN
Zip	:	46526-2311
Country	:	US
Telephone Number	:	574-534-9223
Fax Number	:

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

Provider Enumeration Date	:	11/20/2019
Last Update Date	:	11/20/2019

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Directions to “ STACIA STULTS ” Practice Location

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