Provider Demographics
NPI:1164514832
Name:STOFFREGEN, MISTY CANDACE (RPH)
Entity Type:Individual
Prefix:MS
First Name:MISTY
Middle Name:CANDACE
Last Name:STOFFREGEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 N DONAHUE DR APT 801
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-0206
Mailing Address - Country:US
Mailing Address - Phone:334-826-6975
Mailing Address - Fax:
Practice Address - Street 1:5841 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-2109
Practice Address - Country:US
Practice Address - Phone:334-277-9676
Practice Address - Fax:334-277-9620
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL13657OtherSTATE PHARMACY LICENSE