Healthcare Provider Details

I. General information

NPI: 1992793624
Provider Name (Legal Business Name): JERRY JEAN STAMBAUGH PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

A. G. HOLLEY STATE HOSPITAL 1199 W LANTANA RD
LANTANA FL
33462
US

IV. Provider business mailing address

313 N PALMWAY
LAKE WORTH FL
33460-3518
US

V. Phone/Fax

Practice location:
  • Phone: 561-540-3721
  • Fax: 561-540-3725
Mailing address:
  • Phone: 561-582-6448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS11549
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: