Provider Demographics
NPI:1144590829
Name:STEPHEN, MANOJ
Entity Type:Individual
Prefix:MR
First Name:MANOJ
Middle Name:
Last Name:STEPHEN
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 1:1860 E FOWLER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5511
Mailing Address - Country:US
Mailing Address - Phone:813-977-0651
Mailing Address - Fax:813-632-8030
Practice Address - Street 1:1860 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5511
Practice Address - Country:US
Practice Address - Phone:813-977-0651
Practice Address - Fax:813-632-8030
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist