Provider Demographics
NPI:1407130503
Name:STEVAHN, DWIGHT D
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:D
Last Name:STEVAHN
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:PO BOX 471914
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80047-1914
Mailing Address - Country:US
Mailing Address - Phone:720-870-1385
Mailing Address - Fax:
Practice Address - Street 1:17126 E BETHANY CIR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-2208
Practice Address - Country:US
Practice Address - Phone:720-870-1385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist