Healthcare Provider Details

I. General information

NPI: 1851988489
Provider Name (Legal Business Name): CAROL RENAE GWALTNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 W MAIN ST
WAYNESBORO VA
22980-1619
US

IV. Provider business mailing address

289 STAYMAN LN
STAUNTON VA
24401-8993
US

V. Phone/Fax

Practice location:
  • Phone: 540-949-8871
  • Fax:
Mailing address:
  • Phone: 814-327-3759
  • Fax: 540-949-7934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202211211
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: