Provider Demographics
NPI:1073158366
Name:RAY, STEPHANIE DIANNE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANNE
Last Name:RAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 8TH STREET CT
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-5175
Mailing Address - Country:US
Mailing Address - Phone:309-738-6851
Mailing Address - Fax:
Practice Address - Street 1:3930 44TH AVENUE DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6401
Practice Address - Country:US
Practice Address - Phone:309-736-2275
Practice Address - Fax:309-736-2277
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist