Provider Demographics
NPI:1528380482
Name:KOCH-PREST, STEPHANIE M (RPH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:KOCH-PREST
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:208 S CANPAR WAY
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4538
Mailing Address - Country:US
Mailing Address - Phone:928-600-2498
Mailing Address - Fax:
Practice Address - Street 1:750 W DEUCE OF CLUBS
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-5810
Practice Address - Country:US
Practice Address - Phone:928-537-5234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP027079L183500000X
AZS007118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist