Provider Demographics
NPI:1336566132
Name:OVERTON, STACEY (RPH, PHARMD)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:OVERTON
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9000
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-9000
Mailing Address - Country:US
Mailing Address - Phone:478-272-1210
Mailing Address - Fax:
Practice Address - Street 1:2103 VETERANS BLVD STE 2
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-7531
Practice Address - Country:US
Practice Address - Phone:478-272-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023193183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist