Provider Demographics
NPI:1114213360
Name:GOUGH, ROBERT M (PD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:GOUGH
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 RETAIL COMMONS PARKWAY
Mailing Address - Street 2:T-2538
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403
Mailing Address - Country:US
Mailing Address - Phone:304-264-5201
Mailing Address - Fax:304-264-5201
Practice Address - Street 1:436 RETAIL COMMONS PKWY
Practice Address - Street 2:T-2538
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-6183
Practice Address - Country:US
Practice Address - Phone:304-264-5201
Practice Address - Fax:304-264-5201
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist