Provider Demographics
NPI:1851674758
Name:MUDD-RAY, STACEY (RPH)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MUDD-RAY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CABIN CLUB DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-7414
Mailing Address - Country:US
Mailing Address - Phone:618-550-3635
Mailing Address - Fax:
Practice Address - Street 1:455 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-2885
Practice Address - Country:US
Practice Address - Phone:573-221-6557
Practice Address - Fax:573-248-8041
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist