Provider Demographics
NPI:1326457276
Name:STEVENSON, REGINA (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N C ST
Mailing Address - Street 2:PO BOX 420
Mailing Address - City:PARMA
Mailing Address - State:ID
Mailing Address - Zip Code:83660-5539
Mailing Address - Country:US
Mailing Address - Phone:208-722-6073
Mailing Address - Fax:
Practice Address - Street 1:2100 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6441
Practice Address - Country:US
Practice Address - Phone:208-467-5159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist