Provider Demographics
NPI:1003403817
Name:GASTON, JODY ELAINE
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:ELAINE
Last Name:GASTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936-3400
Mailing Address - Country:US
Mailing Address - Phone:479-996-9898
Mailing Address - Fax:
Practice Address - Street 1:1530 W CENTER ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-3400
Practice Address - Country:US
Practice Address - Phone:479-996-9898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist