Provider Demographics
NPI:1396026597
Name:EMMERTHAL, STEPHEN RYAN
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:RYAN
Last Name:EMMERTHAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 S DAKOTA AVE BLDG 13850
Mailing Address - Street 2:
Mailing Address - City:VANDENBERG AFB
Mailing Address - State:CA
Mailing Address - Zip Code:93437-6307
Mailing Address - Country:US
Mailing Address - Phone:805-606-7440
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE BLDG 13850
Practice Address - Street 2:
Practice Address - City:VANDENBERG AFB
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:805-606-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPI113752390200000X
PARP448731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program