Provider Demographics
NPI:1720011596
Name:STEPHENS HEALTH CARE SPECIALISTS PLLC
Entity Type:Organization
Organization Name:STEPHENS HEALTH CARE SPECIALISTS PLLC
Other - Org Name:CHEYENNE PROFESSIONAL DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-497-3325
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:OK
Mailing Address - Zip Code:73628-0860
Mailing Address - Country:US
Mailing Address - Phone:580-497-3325
Mailing Address - Fax:580-497-3326
Practice Address - Street 1:413 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:OK
Practice Address - Zip Code:73628
Practice Address - Country:US
Practice Address - Phone:580-497-3325
Practice Address - Fax:580-497-3326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7654693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3704182OtherNCPDP PROVIDER IDENTIFICATION NUMBER