Healthcare Provider Details

I. General information

NPI: 1417688318
Provider Name (Legal Business Name): MAGGIE ANN GATEWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8619 WAYNESBURG DR SE
WAYNESBURG OH
44688-9549
US

IV. Provider business mailing address

134 N MAIN ST
WAYNESBURG OH
44688-9438
US

V. Phone/Fax

Practice location:
  • Phone: 330-866-5020
  • Fax: 330-866-9096
Mailing address:
  • Phone: 330-730-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number09201241
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: