Provider Demographics
NPI:1194327759
Name:STEPHEN, WILFORD
Entity type:Individual
Prefix:
First Name:WILFORD
Middle Name:
Last Name:STEPHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 WEST LOOP
Mailing Address - Street 2:
Mailing Address - City:EL CAMPO
Mailing Address - State:TX
Mailing Address - Zip Code:77437-8020
Mailing Address - Country:US
Mailing Address - Phone:979-543-6280
Mailing Address - Fax:
Practice Address - Street 1:3413 WEST LOOP
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-8020
Practice Address - Country:US
Practice Address - Phone:979-543-6280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist