Provider Demographics
NPI:1790375905
Name:STANSBERRY, JEFFREY RUSSELL
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RUSSELL
Last Name:STANSBERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10969 WOOLWICH WAY
Mailing Address - Street 2:
Mailing Address - City:MATHER
Mailing Address - State:CA
Mailing Address - Zip Code:95655
Mailing Address - Country:US
Mailing Address - Phone:916-792-1587
Mailing Address - Fax:
Practice Address - Street 1:1850 W. RIO SALADO PARKWAY
Practice Address - Street 2:SUITE 211
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281
Practice Address - Country:US
Practice Address - Phone:916-926-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0015102183500000X
IL051299865183500000X
AZS024817183500000X
OH03237372183500000X
CA65726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist