Healthcare Provider Details

I. General information

NPI: 1750859971
Provider Name (Legal Business Name): JOSEPH JOHN GAUGHAN III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 3RD ST
DUNMORE PA
18512-2849
US

IV. Provider business mailing address

617 3RD ST
DUNMORE PA
18512-2849
US

V. Phone/Fax

Practice location:
  • Phone: 570-209-7440
  • Fax:
Mailing address:
  • Phone: 570-209-7440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRP450665
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRP450665
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPHARMACY LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: