Provider Demographics
NPI:1154694982
Name:STEPHENS, CLYDE III (RPH)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:
Last Name:STEPHENS
Suffix:III
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 1:1155 FORD RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1099
Mailing Address - Country:US
Mailing Address - Phone:612-284-2197
Mailing Address - Fax:612-808-6759
Practice Address - Street 1:1155 FORD RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1099
Practice Address - Country:US
Practice Address - Phone:612-284-2197
Practice Address - Fax:612-808-6759
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist