Provider Demographics
NPI:1730472028
Name:STANFIELD, OTIS W (RPH)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:W
Last Name:STANFIELD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5028 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-3196
Mailing Address - Country:US
Mailing Address - Phone:731-686-9097
Mailing Address - Fax:731-723-9012
Practice Address - Street 1:5028 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3196
Practice Address - Country:US
Practice Address - Phone:731-686-9097
Practice Address - Fax:731-723-9012
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist