Basic Information
| Provider Information | |||||||||
| NPI: | 1144322074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEWALD | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2838 PIMLICO LN | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486036185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897908093 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 WEISS ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894972500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5302029606 | MI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.