Provider Demographics
NPI:1225139181
Name:STELISE INC
Entity Type:Organization
Organization Name:STELISE INC
Other - Org Name:ENOSBURG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COMEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-933-9200
Mailing Address - Street 1:PO BOX 9830
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9830
Mailing Address - Country:US
Mailing Address - Phone:877-540-4748
Mailing Address - Fax:801-716-4872
Practice Address - Street 1:366 MAIN ST
Practice Address - Street 2:
Practice Address - City:ENOSBURG FALLS
Practice Address - State:VT
Practice Address - Zip Code:05450
Practice Address - Country:US
Practice Address - Phone:802-933-9200
Practice Address - Fax:802-933-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VT038-00033353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2101711OtherPK
VT1009134Medicaid
4814210001Medicare NSC