Provider Demographics
NPI:1124319884
Name:SAMUEL, STACY VALENCIA (PHARM D)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:VALENCIA
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 GOLD PAN RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8622
Mailing Address - Country:US
Mailing Address - Phone:704-502-8052
Mailing Address - Fax:
Practice Address - Street 1:4305 NC HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075
Practice Address - Country:US
Practice Address - Phone:704-454-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist