Provider Demographics
NPI:1003812058
Name:STEPHEN, STEPHEN PETER (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:PETER
Last Name:STEPHEN
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 1:322 CLEMSON CIR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4706
Mailing Address - Country:US
Mailing Address - Phone:903-509-8847
Mailing Address - Fax:
Practice Address - Street 1:1125 N PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-2819
Practice Address - Country:US
Practice Address - Phone:337-462-5796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011937183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist