Provider Demographics
NPI:1689102659
Name:COONS, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:COONS
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 1:4063 EILEEN ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2810
Mailing Address - Country:US
Mailing Address - Phone:805-338-1891
Mailing Address - Fax:
Practice Address - Street 1:351B CARMEN DR
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6033
Practice Address - Country:US
Practice Address - Phone:805-484-3632
Practice Address - Fax:805-445-8448
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66005183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA66005OtherCALIFORNIA BOARD OF PHARMACY