Provider Demographics
NPI:1508039710
Name:STILLWAGON, JEFFREY WARREN (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WARREN
Last Name:STILLWAGON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 HILLANDALE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2664
Mailing Address - Country:US
Mailing Address - Phone:919-383-7495
Mailing Address - Fax:919-383-7955
Practice Address - Street 1:1901 HILLANDALE RD
Practice Address - Street 2:SUITE C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2664
Practice Address - Country:US
Practice Address - Phone:919-383-7495
Practice Address - Fax:919-383-7955
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6502183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist