Provider Demographics
NPI:1174952410
Name:STACK, GILLIAN
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2746 TONAQUINT DR
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7671
Mailing Address - Country:US
Mailing Address - Phone:435-215-6745
Mailing Address - Fax:
Practice Address - Street 1:180 N 3400 W
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-3031
Practice Address - Country:US
Practice Address - Phone:435-635-2014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT273247-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist