Provider Demographics
NPI:1295036739
Name:RODENBURG, STEPHANIE (BS)
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:
Last Name:RODENBURG
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-6279
Mailing Address - Country:US
Mailing Address - Phone:541-736-3418
Mailing Address - Fax:541-736-3415
Practice Address - Street 1:5415 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6279
Practice Address - Country:US
Practice Address - Phone:541-736-3418
Practice Address - Fax:541-736-3415
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist