Provider Demographics
NPI:1316087257
Name:STIMLEY, JASON ANTHONY (RPH)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ANTHONY
Last Name:STIMLEY
Suffix:
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 1:3711 N 100 W
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-7858
Mailing Address - Country:US
Mailing Address - Phone:219-362-3180
Mailing Address - Fax:
Practice Address - Street 1:702 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3889
Practice Address - Country:US
Practice Address - Phone:219-362-7133
Practice Address - Fax:219-362-2833
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019517A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist