Provider Demographics
NPI:1104411537
Name:BLACK, STEPHEN ANTHONY (PD)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ANTHONY
Last Name:BLACK
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 COUNTY ROAD 1147
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35057-1211
Mailing Address - Country:US
Mailing Address - Phone:256-338-2217
Mailing Address - Fax:256-615-6666
Practice Address - Street 1:145 COUNTY ROAD 1147
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35057-1211
Practice Address - Country:US
Practice Address - Phone:256-338-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL9944OtherALABAMA STATE BOARD OF PHARMACY