Provider Demographics
NPI:1750982245
Name:WHITAKER, STEPHANIE DIANE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANE
Last Name:WHITAKER
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 1:3797 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SNYDER
Mailing Address - State:TX
Mailing Address - Zip Code:79549-5317
Mailing Address - Country:US
Mailing Address - Phone:940-210-0245
Mailing Address - Fax:
Practice Address - Street 1:5110 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SNYDER
Practice Address - State:TX
Practice Address - Zip Code:79549-6112
Practice Address - Country:US
Practice Address - Phone:325-573-1965
Practice Address - Fax:325-573-3312
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist