Healthcare Provider Details

I. General information

NPI: 1053392290
Provider Name (Legal Business Name): LARRY D GUDGEL PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5210, BOX 230
APO AE
09461
GB

IV. Provider business mailing address

PSC 41 BOX 6891
APO AE
09464
GB

V. Phone/Fax

Practice location:
  • Phone: 011441638528302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number10049
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: