Provider Demographics
NPI:1629363296
Name:STILLWAGON, CHAD MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:MICHAEL
Last Name:STILLWAGON
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 1:16825 E SHEA BLVD
Mailing Address - Street 2:T-1432
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-6668
Mailing Address - Country:US
Mailing Address - Phone:480-837-8563
Mailing Address - Fax:
Practice Address - Street 1:16825 E SHEA BLVD
Practice Address - Street 2:T-1432
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-6668
Practice Address - Country:US
Practice Address - Phone:480-837-8563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS013214183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist