Provider Demographics
NPI:1447311881
Name:STEVENS, MARK T (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:STEVENS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 SILVER OAK TRL
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-4088
Mailing Address - Country:US
Mailing Address - Phone:512-296-2496
Mailing Address - Fax:512-296-2496
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:36000 DARNALL LOOP
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:210-930-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist