Provider Demographics
NPI:1427658806
Name:GODWIN, STEPHANIE RUSSO (PHARM D)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RUSSO
Last Name:GODWIN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MAE
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4424 STOCKTON RD
Mailing Address - Street 2:
Mailing Address - City:POCOMOKE CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21851-2512
Mailing Address - Country:US
Mailing Address - Phone:410-726-2117
Mailing Address - Fax:
Practice Address - Street 1:2132 OLD SNOW HILL RD
Practice Address - Street 2:
Practice Address - City:POCOMOKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21851-2734
Practice Address - Country:US
Practice Address - Phone:410-726-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist