Provider Demographics
NPI:1821690520
Name:STEPHENS, MARLA SERENE
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:SERENE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40019 S COUNTY ROAD
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462
Mailing Address - Country:US
Mailing Address - Phone:918-916-2143
Mailing Address - Fax:
Practice Address - Street 1:1312 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-2830
Practice Address - Country:US
Practice Address - Phone:918-967-3369
Practice Address - Fax:918-967-4461
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist