Provider Demographics
NPI:1063016947
Name:TALWAR, GAUTAM (RPH)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:TALWAR
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 SOUTHPARK BLVD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3604
Mailing Address - Country:US
Mailing Address - Phone:804-526-0636
Mailing Address - Fax:
Practice Address - Street 1:671 SOUTHPARK BLVD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3604
Practice Address - Country:US
Practice Address - Phone:804-526-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist