Provider Demographics
NPI:1063967362
Name:STEPHENS, JILLIAN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-9667
Mailing Address - Country:US
Mailing Address - Phone:419-512-1662
Mailing Address - Fax:
Practice Address - Street 1:424 N BRIGHTLEAF BLVD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4674
Practice Address - Country:US
Practice Address - Phone:919-989-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25724183500000X
OH03233197183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist