Healthcare Provider Details

I. General information

NPI: 1477689479
Provider Name (Legal Business Name): GAYLORD EARL VICTORA R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 EDGINGTON AVE
ELDORA IA
50627-1626
US

IV. Provider business mailing address

2213 N TERRACE DR
WEBSTER CITY IA
50595-3026
US

V. Phone/Fax

Practice location:
  • Phone: 641-858-3567
  • Fax:
Mailing address:
  • Phone: 515-832-5284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15091
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: