Provider Demographics
NPI:1316105026
Name:BRANCH, STEPHEN A (RPH)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:BRANCH
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 1:1202 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-2507
Mailing Address - Country:US
Mailing Address - Phone:361-552-2999
Mailing Address - Fax:361-552-1566
Practice Address - Street 1:1202 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-2507
Practice Address - Country:US
Practice Address - Phone:361-552-2999
Practice Address - Fax:361-552-1566
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX013985901Medicaid
TX010801101Medicaid
TX013985901Medicaid