Provider Demographics
NPI:1699050591
Name:STANG, MARK WILLIAM I
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:STANG
Suffix:I
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 1:5054 S 133RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1759
Mailing Address - Country:US
Mailing Address - Phone:402-894-0291
Mailing Address - Fax:
Practice Address - Street 1:5054 S 133RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1759
Practice Address - Country:US
Practice Address - Phone:402-894-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist