Provider Demographics
NPI:1972191583
Name:DETHERAGE, STEFFFEN SCOTT
Entity Type:Individual
Prefix:
First Name:STEFFFEN
Middle Name:SCOTT
Last Name:DETHERAGE
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 1:4940 S GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-4552
Mailing Address - Country:US
Mailing Address - Phone:480-883-2241
Mailing Address - Fax:
Practice Address - Street 1:4940 S GILBERT RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-4552
Practice Address - Country:US
Practice Address - Phone:480-883-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS026610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist