=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053928952
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN GRACE CUERVO PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2020
-----------------------------------------------------
Last Update Date | 09/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 COLLIERS WAY
-----------------------------------------------------
City | WEIRTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26062-5014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-797-6070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 WESTBROOKE LN
-----------------------------------------------------
City | CORAOPOLIS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15108-9139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-352-5519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP0011164
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------