Provider Demographics
NPI:1306961214
Name:BRUCE, STACEY LEA (PHARM D)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LEA
Last Name:BRUCE
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 1:369 ANTEBELLUM LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7871
Mailing Address - Country:US
Mailing Address - Phone:843-412-5705
Mailing Address - Fax:
Practice Address - Street 1:RALPH H JOHNSON VA MEDICAL CENTER
Practice Address - Street 2:109 BEE STREET
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5799
Practice Address - Country:US
Practice Address - Phone:843-789-6583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC98611835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC12583OtherPHARMACIST