Provider Demographics
NPI:1346591377
Name:STEVENS, STAN R (RPH)
Entity type:Individual
Prefix:
First Name:STAN
Middle Name:R
Last Name:STEVENS
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 1:9385 FAIRVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1582
Mailing Address - Country:US
Mailing Address - Phone:317-776-1269
Mailing Address - Fax:
Practice Address - Street 1:9385 FAIRVIEW PKWY
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1582
Practice Address - Country:US
Practice Address - Phone:317-776-1269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-09720183500000X
IN26022596A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist