Provider Demographics
NPI:1750915369
Name:VAN, STACEY ERICA
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ERICA
Last Name:VAN
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 1:800 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-4976
Mailing Address - Country:US
Mailing Address - Phone:408-842-0373
Mailing Address - Fax:408-842-3656
Practice Address - Street 1:800 1ST ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4976
Practice Address - Country:US
Practice Address - Phone:408-942-0373
Practice Address - Fax:408-842-3656
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81714183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist