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General NPI Number Information
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NPI Number | 1134720675
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Entity Type | Individual
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Provider Name | ANDREW WAYNE STINE
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Gender | Male
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Dates
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Enumeration Date | 11/02/2020
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Last Update Date | 11/02/2020
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Provider Practice Location Address
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Address Line | 6100 RONALD REAGAN DR
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City | LAKE SAINT LOUIS
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State | MO
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Zip | 63367-2660
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Country | US
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Telephone | 479-420-1320
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Fax |
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Provider Business Mailing Address
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Address Line | 1402 HOMESTEAD VALLEY DR
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City | WILDWOOD
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State | MO
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Zip | 63005-8446
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Country | US
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Telephone | 636-328-5887
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 043655
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License Number State | MO
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