Provider Demographics
NPI:1326640863
Name:STALLWORTH, ADERO KAIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:ADERO
Middle Name:KAIA
Last Name:STALLWORTH
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 1:165 LONE OAK DR
Mailing Address - Street 2:
Mailing Address - City:EADS
Mailing Address - State:TN
Mailing Address - Zip Code:38028-3361
Mailing Address - Country:US
Mailing Address - Phone:901-494-6538
Mailing Address - Fax:
Practice Address - Street 1:6520 MEMPHIS ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38135-2402
Practice Address - Country:US
Practice Address - Phone:901-388-4331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000041804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist