Provider Demographics
NPI:1396349700
Name:STEPANIAK, CRYSTA
Entity type:Individual
Prefix:
First Name:CRYSTA
Middle Name:
Last Name:STEPANIAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 STATE ROAD 20
Mailing Address - Street 2:
Mailing Address - City:INTERLACHEN
Mailing Address - State:FL
Mailing Address - Zip Code:32148-5406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1141 STATE ROAD 20
Practice Address - Street 2:
Practice Address - City:INTERLACHEN
Practice Address - State:FL
Practice Address - Zip Code:32148-5406
Practice Address - Country:US
Practice Address - Phone:386-684-4991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist