Provider Demographics
NPI:1881863868
Name:WYATT, STEPHEN EDWARD (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:EDWARD
Last Name:WYATT
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 E AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2845
Mailing Address - Country:US
Mailing Address - Phone:936-564-7373
Mailing Address - Fax:936-564-9338
Practice Address - Street 1:917 E AUSTIN ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2845
Practice Address - Country:US
Practice Address - Phone:936-564-7373
Practice Address - Fax:936-564-9338
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist