Provider Demographics
NPI:1992060081
Name:STIMPSON, DANIEL SHANE (RPH)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:SHANE
Last Name:STIMPSON
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 1:1850 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5702
Mailing Address - Country:US
Mailing Address - Phone:208-887-5273
Mailing Address - Fax:
Practice Address - Street 1:1850 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5702
Practice Address - Country:US
Practice Address - Phone:208-887-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6521183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist