Provider Demographics
NPI:1629167242
Name:SMALL, STEPHEN ANTHONY (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ANTHONY
Last Name:SMALL
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 1:1006 BRETTWALD DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-9414
Mailing Address - Country:US
Mailing Address - Phone:304-599-9235
Mailing Address - Fax:800-531-7787
Practice Address - Street 1:1006 BRETTWALD DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-9414
Practice Address - Country:US
Practice Address - Phone:304-599-9235
Practice Address - Fax:800-531-7787
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0003299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist