Provider Demographics
NPI:1457633521
Name:STEFANAVAGE, LISA (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STEFANAVAGE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-3010
Mailing Address - Country:US
Mailing Address - Phone:302-654-1834
Mailing Address - Fax:
Practice Address - Street 1:839 N MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-3010
Practice Address - Country:US
Practice Address - Phone:302-654-1834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0003018183500000X
PARP-044788-L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist