Provider Demographics
NPI:1497098479
Name:GUSTAFSON, STEPHANIE FLIESS (RPH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:FLIESS
Last Name:GUSTAFSON
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 1:6655 TRAVIS ST
Mailing Address - Street 2:SUITE 490
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1312
Mailing Address - Country:US
Mailing Address - Phone:713-500-8385
Mailing Address - Fax:713-500-8384
Practice Address - Street 1:6655 TRAVIS ST
Practice Address - Street 2:SUITE 490
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1312
Practice Address - Country:US
Practice Address - Phone:713-500-8385
Practice Address - Fax:713-500-8384
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26213183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist