Healthcare Provider Details

I. General information

NPI: 1225386188
Provider Name (Legal Business Name): GWENDOLINN LOUISE STAUD PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 STATE ROUTE 20
PINE GROVE WV
26419
US

IV. Provider business mailing address

PO BOX 389
PINE GROVE WV
26419-0389
US

V. Phone/Fax

Practice location:
  • Phone: 304-889-3131
  • Fax: 304-889-3315
Mailing address:
  • Phone: 304-889-3131
  • Fax: 304-889-3315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007886
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: