Provider Demographics
NPI:1063020022
Name:BAILEY, STEPHEN BRYAN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BRYAN
Last Name:BAILEY
Suffix:
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 1:2825 WINDRUSH DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-3820
Mailing Address - Country:US
Mailing Address - Phone:260-433-6726
Mailing Address - Fax:
Practice Address - Street 1:2100 GOSHEN RD STE 111
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-1493
Practice Address - Country:US
Practice Address - Phone:260-203-0998
Practice Address - Fax:260-267-6900
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017207A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist