Provider Demographics
NPI:1639264062
Name:DISTEFANO, DEBORAH SUE (CPHT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:SUE
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56667 ORCHARD LANE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013
Mailing Address - Country:US
Mailing Address - Phone:269-427-5279
Mailing Address - Fax:
Practice Address - Street 1:512 PHOENIX STREET
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090
Practice Address - Country:US
Practice Address - Phone:269-637-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2215-0902-2083-111183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician