Provider Demographics
NPI:1144805573
Name:LECLAIR, GWENDOLYN MARIE (CPHT)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MARIE
Last Name:LECLAIR
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2424
Mailing Address - Country:US
Mailing Address - Phone:860-928-4199
Mailing Address - Fax:860-928-7531
Practice Address - Street 1:625 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2424
Practice Address - Country:US
Practice Address - Phone:860-928-4199
Practice Address - Fax:860-928-7531
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTY8Z6Z4Z5183700000X
CTPTN0013330183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician