Provider Demographics
NPI:1780345934
Name:FUENTES, STEPHANIE DIANA (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANA
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BLOSSOM ST STE 105
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4225
Mailing Address - Country:US
Mailing Address - Phone:832-632-7970
Mailing Address - Fax:
Practice Address - Street 1:250 BLOSSOM ST STE 105
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4225
Practice Address - Country:US
Practice Address - Phone:832-632-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-09
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74666183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist