Provider Demographics
NPI:1285162479
Name:STEVENS, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 W DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07885-1656
Mailing Address - Country:US
Mailing Address - Phone:734-717-8089
Mailing Address - Fax:
Practice Address - Street 1:1483 STATE RT 23 STE 12
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-1643
Practice Address - Country:US
Practice Address - Phone:973-838-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03537300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist