Provider Demographics
NPI:1720488695
Name:STEVENS, JIMMY JR
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:STEVENS
Suffix:JR
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 1:4242 E CACTUS RD
Mailing Address - Street 2:APT 134
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-7674
Mailing Address - Country:US
Mailing Address - Phone:425-876-0486
Mailing Address - Fax:
Practice Address - Street 1:10160 E BELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2340
Practice Address - Country:US
Practice Address - Phone:425-876-0486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist