Healthcare Provider Details

I. General information

NPI: 1740373638
Provider Name (Legal Business Name): KENRIC LAMAR STEPHENS PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W PERIMETER RD 79TH MDSS/SGSP
ANDREWS AIR FORCE BASE MD
20762-6601
US

IV. Provider business mailing address

4611 SHARON RD
CAMP SPRINGS MD
20748-3737
US

V. Phone/Fax

Practice location:
  • Phone: 240-857-3689
  • Fax: 240-854-4544
Mailing address:
  • Phone: 301-702-3016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS18999
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17177
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: