Provider Demographics
NPI:1578194692
Name:GARTRELL, STEPHANIE LEE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEE
Last Name:GARTRELL
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 1:7533 KIDWELL DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-6836
Mailing Address - Country:US
Mailing Address - Phone:317-502-0259
Mailing Address - Fax:
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026275A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INNAOtherNA