Provider Demographics
NPI:1740563006
Name:TRISTANO, STEPHANIE GRACE (PHARMD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GRACE
Last Name:TRISTANO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 CHATFIELD DR APT C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2680
Mailing Address - Country:US
Mailing Address - Phone:773-547-3650
Mailing Address - Fax:
Practice Address - Street 1:1215 S RANGE LINE RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2519
Practice Address - Country:US
Practice Address - Phone:317-571-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024169A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist