Healthcare Provider Details

I. General information

NPI: 1902116338
Provider Name (Legal Business Name): JASON ROMAN GEVENOSKY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2987 ROBERT C BYRD DR
BECKLEY WV
25801-4400
US

IV. Provider business mailing address

150 TWIN OAKS DRIVE
SHADY SPRING WV
25918
US

V. Phone/Fax

Practice location:
  • Phone: 304-252-6331
  • Fax: 304-252-0075
Mailing address:
  • Phone: 304-763-3593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0006766
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: