Provider Demographics
NPI:1750666954
Name:SHIDEMANTLE, STEPHANIE LYNN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LYNN
Last Name:SHIDEMANTLE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:DRIGGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:414C MARY ESTHER CTO NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4060
Mailing Address - Country:US
Mailing Address - Phone:850-244-0869
Mailing Address - Fax:850-244-1403
Practice Address - Street 1:414C MARY ESTHER CTO NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4060
Practice Address - Country:US
Practice Address - Phone:850-244-0869
Practice Address - Fax:850-244-1403
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS50073183500000X
GA023927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist