Provider Demographics
NPI:1134720675
Name:STINE, ANDREW WAYNE
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WAYNE
Last Name:STINE
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 1:1402 HOMESTEAD VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-8446
Mailing Address - Country:US
Mailing Address - Phone:636-328-5887
Mailing Address - Fax:
Practice Address - Street 1:6100 RONALD REAGAN DR
Practice Address - Street 2:
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-2660
Practice Address - Country:US
Practice Address - Phone:479-420-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist