MEDICARE: CARMEN MARIE STACH

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	2017028106	MO

General Provider Information

NPI Number	:	1972089852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARMEN MARIE STACH

Provider Business Mailing Address
First Line	:	4050 W PINE BLVD APT 3205
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-3349
Country	:	US
Telephone Number	:	763-276-6759
Fax Number	:

Provider Business Practice Location Address
First Line	:	4050 W PINE BLVD
Second Line	:	APT 3205
City	:	ST. LOUIS
State	:	MO
Zip	:	63131-6313
Country	:	US
Telephone Number	:	763-276-6759
Fax Number	:

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

Provider Enumeration Date	:	07/13/2018
Last Update Date	:	07/13/2018

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