Provider Demographics
NPI:1932221348
Name:WILLIS, STEPHEN DEAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DEAN
Last Name:WILLIS
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 1:2345 26TH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-1642
Mailing Address - Country:US
Mailing Address - Phone:319-377-3512
Mailing Address - Fax:
Practice Address - Street 1:402 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:IA
Practice Address - Zip Code:52214-9454
Practice Address - Country:US
Practice Address - Phone:319-438-1988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist