Provider Demographics
NPI:1649764572
Name:STADE, JAY
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:STADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-3908
Mailing Address - Country:US
Mailing Address - Phone:620-727-6508
Mailing Address - Fax:
Practice Address - Street 1:2003 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-8460
Practice Address - Country:US
Practice Address - Phone:620-672-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-13001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist