Healthcare Provider Details

I. General information

NPI: 1053696518
Provider Name (Legal Business Name): WILLIAM STEPHEN STANLEY R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 SOUTH SECOND STREET DEL NORTE PHARMACY
RATON NM
87740
US

IV. Provider business mailing address

PO BOX 1841
RATON NM
87740
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-5163
  • Fax: 575-445-5393
Mailing address:
  • Phone: 520-921-9495
  • Fax: 575-445-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License NumberRP00004818
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: