Provider Demographics
NPI:1205962073
Name:STEPHENS PHARMACY
Entity type:Organization
Organization Name:STEPHENS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-686-3735
Mailing Address - Street 1:430 WILLIAM HILTON PKWY
Mailing Address - Street 2:SUITE 302 B
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-2424
Mailing Address - Country:US
Mailing Address - Phone:843-686-3735
Mailing Address - Fax:843-686-3035
Practice Address - Street 1:430 WILLIAM HILTON PKWY
Practice Address - Street 2:SUITE 302 B
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-2424
Practice Address - Country:US
Practice Address - Phone:843-686-3735
Practice Address - Fax:843-686-3035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50006936183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC50006936OtherPHARMACY PERMIT