Provider Demographics
NPI:1245557651
Name:WATERS, STEPHEN (RPH, PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:RPH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 W MAIN ST
Mailing Address - Street 2:WALGREENS PHARMACY
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3428
Mailing Address - Country:US
Mailing Address - Phone:203-488-9059
Mailing Address - Fax:203-488-9163
Practice Address - Street 1:1036 W MAIN ST
Practice Address - Street 2:WALGREENS PHARMACY
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3428
Practice Address - Country:US
Practice Address - Phone:203-488-9059
Practice Address - Fax:203-488-9163
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-24
Last Update Date:2010-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0011036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist