MEDICARE: DR. JERRY JEAN STAMBAUGH PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS11549	FL

General Provider Information

NPI Number	:	1992793624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY JEAN STAMBAUGH PHARM.D.

Provider Business Mailing Address
First Line	:	313 N PALMWAY
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-3518
Country	:	US
Telephone Number	:	561-582-6448
Fax Number	:

Provider Business Practice Location Address
First Line	:	A. G. HOLLEY STATE HOSPITAL
Second Line	:	1199 W LANTANA RD
City	:	LANTANA
State	:	FL
Zip	:	33462
Country	:	US
Telephone Number	:	561-540-3721
Fax Number	:	561-540-3725

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	07/08/2007

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