Provider Demographics
NPI:1770898660
Name:GORMAN-HACKSTADT, STEVEN F (RPH)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:F
Last Name:GORMAN-HACKSTADT
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 1:1541 N BLUE GRASS RANCH DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-9776
Mailing Address - Country:US
Mailing Address - Phone:928-367-6177
Mailing Address - Fax:
Practice Address - Street 1:5160 S WHITE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7826
Practice Address - Country:US
Practice Address - Phone:928-532-5502
Practice Address - Fax:928-532-5499
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist