Provider Demographics
NPI:1225386188
Name:STAUD, GWENDOLINN LOUISE (PHARMD)
Entity Type:Individual
Prefix:
First Name:GWENDOLINN
Middle Name:LOUISE
Last Name:STAUD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 389
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:26419-0389
Mailing Address - Country:US
Mailing Address - Phone:304-889-3131
Mailing Address - Fax:304-889-3315
Practice Address - Street 1:300 STATE ROUTE 20
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:WV
Practice Address - Zip Code:26419
Practice Address - Country:US
Practice Address - Phone:304-889-3131
Practice Address - Fax:304-889-3315
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP00007886183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist