Provider Demographics
NPI:1942614649
Name:COSTELLO, STEPHEN JR
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:COSTELLO
Suffix:JR
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 1:135 WINDERS LN
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-3058
Mailing Address - Country:US
Mailing Address - Phone:757-812-4649
Mailing Address - Fax:
Practice Address - Street 1:2460 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:HAYES
Practice Address - State:VA
Practice Address - Zip Code:23072
Practice Address - Country:US
Practice Address - Phone:804-642-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009277183500000X
MA190121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist