Provider Demographics
NPI:1275295438
Name:CLEMENS, STEFANIE J
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:J
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1859
Mailing Address - Country:US
Mailing Address - Phone:989-732-5220
Mailing Address - Fax:989-731-4216
Practice Address - Street 1:419 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1859
Practice Address - Country:US
Practice Address - Phone:989-732-5220
Practice Address - Fax:989-731-4216
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303006082183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician