Provider Demographics
NPI:1942474606
Name:STEPHENSON, BROOKE
Entity Type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:
Last Name:STEPHENSON
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 1:1300 ULSTER AVE STE 227
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-8102
Mailing Address - Country:US
Mailing Address - Phone:845-336-6030
Mailing Address - Fax:
Practice Address - Street 1:1300 ULSTER AVE STE 227
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-8102
Practice Address - Country:US
Practice Address - Phone:845-336-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044995183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist