Stacie Ely, RPH
Individual provider Active NPI Pharmacist · Ava, MO
NPI 1154922052 · NPPES record last updated Apr 5, 2022
Key facts
- NPI
- 1154922052
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- 2000166259 (MO)
- Practice address
- 1309 NW 12TH Ave
Ava, MO 65608 - Phone
- (417) 683-4708
- NPI assigned
- Nov 5, 2020
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2000166259 | MO | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Wal-Mart Stores East, LP | Past |
Accepting new patients | |
| Wal-Mart Stores East LP | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 2000166259 | MO | Yes |
Addresses
Primary practice location
1309 NW 12TH Ave
Ava, MO 65608
Mailing address
507 Primrose LN
Houston, MO 65483-2106
Other practice location 1
1433 S Sam Houston Blvd
Houston, MO 65483-2131
Phone (417) 967-4521
Other providers in Ava, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 5, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.