Healthcare Provider Details

I. General information

NPI: 1699785683
Provider Name (Legal Business Name): DERA LEIGH STALNAKER PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 BLUFF CITY HIGHWAY
BRISTOL TN
37600
US

IV. Provider business mailing address

310 BLUFF CITY HIGHWAY
BRISTOL TN
37600
US

V. Phone/Fax

Practice location:
  • Phone: 423-764-4136
  • Fax: 423-764-5167
Mailing address:
  • Phone: 423-764-4136
  • Fax: 423-764-5167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24207
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: