Provider Demographics
NPI:1396284691
Name:STACKONIS, LARA PEREA
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:PEREA
Last Name:STACKONIS
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 1:904 LAS LOMAS RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2633
Mailing Address - Country:US
Mailing Address - Phone:505-924-2661
Mailing Address - Fax:720-914-3341
Practice Address - Street 1:904 LAS LOMAS RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2633
Practice Address - Country:US
Practice Address - Phone:505-924-2661
Practice Address - Fax:720-914-3341
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00005571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist