Healthcare Provider Details

I. General information

NPI: 1528380482
Provider Name (Legal Business Name): STEPHANIE M KOCH-PREST RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE M KOCH RPH

II. Dates (important events)

Enumeration Date: 02/19/2010
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W DEUCE OF CLUBS
SHOW LOW AZ
85901-5810
US

IV. Provider business mailing address

208 S CANPAR WAY
PAYSON AZ
85541-4538
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-5234
  • Fax:
Mailing address:
  • Phone: 928-600-2498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP027079L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS007118
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: