Provider Demographics
NPI:1225181514
Name:STATEN, DELANA DENEISE (RPH)
Entity Type:Individual
Prefix:
First Name:DELANA
Middle Name:DENEISE
Last Name:STATEN
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 1:13624 SPUR 364
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75709-5135
Mailing Address - Country:US
Mailing Address - Phone:903-593-0854
Mailing Address - Fax:903-593-8737
Practice Address - Street 1:13321 FM 206 HWY 31 W
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75709
Practice Address - Country:US
Practice Address - Phone:903-592-3487
Practice Address - Fax:903-593-8737
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist