Provider Demographics
NPI:1972141372
Name:STOCKDALE, MARK ERIC (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ERIC
Last Name:STOCKDALE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20645 GIBRALTAR RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-5087
Mailing Address - Country:US
Mailing Address - Phone:734-675-0656
Mailing Address - Fax:734-675-0961
Practice Address - Street 1:20645 GIBRALTAR RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-5087
Practice Address - Country:US
Practice Address - Phone:734-675-0656
Practice Address - Fax:734-675-0961
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020271941835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist