=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508171273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLADYS BAUZON BAKKEN RPH, CIP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2010
-----------------------------------------------------
Last Update Date | 08/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1430 BALTIMORE ST
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17331-8529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-632-8833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 SYCAMORE CT
-----------------------------------------------------
City | LITTLESTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17340-9239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-337-1467
-----------------------------------------------------
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 | RP441652
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 18126
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------