Provider Demographics
NPI:1174632855
Name:STALLBOHM, GRETCHEN E (RPH)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:E
Last Name:STALLBOHM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 BURTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FULTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12072-3242
Mailing Address - Country:US
Mailing Address - Phone:518-922-5386
Mailing Address - Fax:
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05009-0001
Practice Address - Country:US
Practice Address - Phone:802-295-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3248183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist