Provider Demographics
NPI:1558961946
Name:PADDOCK, STEPANIE ANN
Entity Type:Individual
Prefix:
First Name:STEPANIE
Middle Name:ANN
Last Name:PADDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 W RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4668
Mailing Address - Country:US
Mailing Address - Phone:417-241-4170
Mailing Address - Fax:
Practice Address - Street 1:3315 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4914
Practice Address - Country:US
Practice Address - Phone:417-881-6750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018029989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist