Provider Demographics
NPI:1124615075
Name:NGUYEN, STEPHANIE ROSE (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROSE
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15960 DAM RD
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-7906
Mailing Address - Country:US
Mailing Address - Phone:707-994-1671
Mailing Address - Fax:
Practice Address - Street 1:15960 DAM RD
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-7906
Practice Address - Country:US
Practice Address - Phone:707-994-1671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH83535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist