# STAFFORD MEDICAL PA

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** MEDVANTX INC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1093052102
- **Legal business name:** MEDVANTX INC
- **Authorized official:** KENNY HEINE (VP OPS)
- **Authorized official phone:** (858) 964-1506

## Contact information

- **Practice address:** 1364 ROUTE 72 W, 2, MANAHAWKIN, NJ 08050-2485
- **Practice address phone:** (609) 597-3416
- **Mailing address:** 5626 OBERLIN DR, 110, SAN DIEGO, CA 92121-1705

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332900000X | Non-Pharmacy Dispensing Site | 25MA066536 | NJ | Yes |

## Other

- **Enumeration date:** 01/09/2013
- **Last updated:** 01/09/2013