Provider Demographics
NPI:1720557564
Name:STEPHEN, ANTONIO JR
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:STEPHEN
Suffix:JR
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 1:5941 FISHER RD APT 104
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-5911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7050 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-5333
Practice Address - Country:US
Practice Address - Phone:301-449-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-22
Last Update Date:2018-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202215411183500000X
MD25988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist