Provider Demographics
NPI:1043659402
Name:VINCENT, FAE CLEDA (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:FAE
Middle Name:CLEDA
Last Name:VINCENT
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6945 BEVERLY PIKE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-7852
Mailing Address - Country:US
Mailing Address - Phone:304-366-8297
Mailing Address - Fax:
Practice Address - Street 1:2800 MEADOWBROOK MALL
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9795
Practice Address - Country:US
Practice Address - Phone:304-842-7779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist