Provider Demographics
NPI:1093327900
Name:PERRY, STEPHEN NATHANIEL
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:NATHANIEL
Last Name:PERRY
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:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-0604
Mailing Address - Country:US
Mailing Address - Phone:304-563-8562
Mailing Address - Fax:
Practice Address - Street 1:111 4TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-1219
Practice Address - Country:US
Practice Address - Phone:304-523-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0011718183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist