Healthcare Provider Details

I. General information

NPI: 1609321678
Provider Name (Legal Business Name): GREGORY CANTWELL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

IV. Provider business mailing address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

V. Phone/Fax

Practice location:
  • Phone: 360-575-4841
  • Fax: 360-636-6249
Mailing address:
  • Phone: 360-575-4841
  • Fax: 360-636-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00010950
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: