Provider Demographics
NPI:1770192783
Name:STOUT, JESSICA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STOUT
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 1:630 EASTVIEW CT APT A
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-2879
Mailing Address - Country:US
Mailing Address - Phone:864-764-0484
Mailing Address - Fax:
Practice Address - Street 1:2707 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-9406
Practice Address - Country:US
Practice Address - Phone:803-366-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-26
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist