Healthcare Provider Details

I. General information

NPI: 1659661114
Provider Name (Legal Business Name): JAVONNA STEVENS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

900 S. BOARDMAN APT. E45
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1185
  • Fax:
Mailing address:
  • Phone: 443-506-4771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202210120
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: