Provider Demographics
NPI:1558795039
Name:STAFFORD, JESSICA LAUREN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LAUREN
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-1927
Mailing Address - Country:US
Mailing Address - Phone:216-272-2620
Mailing Address - Fax:
Practice Address - Street 1:415 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1927
Practice Address - Country:US
Practice Address - Phone:216-272-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2019-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP448112183500000X
NMRP00008347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist