Provider Demographics
NPI:1205353158
Name:ADAMS, STAN DEWAYNE (RPH)
Entity type:Individual
Prefix:
First Name:STAN
Middle Name:DEWAYNE
Last Name:ADAMS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12101 HIGHWAY 57
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-7199
Mailing Address - Country:US
Mailing Address - Phone:228-826-9576
Mailing Address - Fax:228-826-9578
Practice Address - Street 1:12101 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-7199
Practice Address - Country:US
Practice Address - Phone:228-826-9576
Practice Address - Fax:228-826-9578
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE7769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist