=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104349059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEVON JANEAN EFAW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2017
-----------------------------------------------------
Last Update Date | 12/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 S PIKE ST
-----------------------------------------------------
City | SHINNSTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26431-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-592-8003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4674 HUSKY HWY
-----------------------------------------------------
City | MANNINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26582-7150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-365-2418
-----------------------------------------------------
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 | RP0010195
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------