Provider Demographics
NPI:1487932075
Name:HARBERTSON, STACY RAE
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:RAE
Last Name:HARBERTSON
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 1:6431 S 1865 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2119
Mailing Address - Country:US
Mailing Address - Phone:801-440-4063
Mailing Address - Fax:
Practice Address - Street 1:1110 S 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3053
Practice Address - Country:US
Practice Address - Phone:801-401-9563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7115078-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist