Provider Demographics
NPI:1750478277
Name:STEVENS, MARIE MIDDLECOFF (DPH)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:MIDDLECOFF
Last Name:STEVENS
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9234 FLETCHER TRACE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-9201
Mailing Address - Country:US
Mailing Address - Phone:901-371-0411
Mailing Address - Fax:
Practice Address - Street 1:13092 N MAIN STREET
Practice Address - Street 2:SUPER DRUGS
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068
Practice Address - Country:US
Practice Address - Phone:901-465-9888
Practice Address - Fax:901-465-6906
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist