Provider Demographics
NPI:1992793624
Name:STAMBAUGH, JERRY JEAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JEAN
Last Name:STAMBAUGH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 N PALMWAY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-3518
Mailing Address - Country:US
Mailing Address - Phone:561-582-6448
Mailing Address - Fax:
Practice Address - Street 1:A. G. HOLLEY STATE HOSPITAL
Practice Address - Street 2:1199 W LANTANA RD
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462
Practice Address - Country:US
Practice Address - Phone:561-540-3721
Practice Address - Fax:561-540-3725
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS11549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist