Provider Demographics
NPI:1306493929
Name:PORTER, STEPHEN BENJAMIN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BENJAMIN
Last Name:PORTER
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 1:350 W WOODROW WILSON AVE RM ME101-42
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-984-4223
Mailing Address - Fax:
Practice Address - Street 1:350 W WOODROW WILSON AVE RM ME101-42
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-984-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57692183500000X
MSE-12577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist