Provider Demographics
NPI:1962577528
Name:STEWART, DOUGLAS M (RPH)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:M
Last Name:STEWART
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 1:17 MYRNA ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2125
Mailing Address - Country:US
Mailing Address - Phone:304-472-5297
Mailing Address - Fax:
Practice Address - Street 1:4 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2753
Practice Address - Country:US
Practice Address - Phone:304-472-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0002513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0142362000Medicaid
WV0142362000Medicaid