Provider Demographics
NPI:1467732685
Name:WADE, GWENDOLYN (BS)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 ABINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-3547
Mailing Address - Country:US
Mailing Address - Phone:727-866-3831
Mailing Address - Fax:
Practice Address - Street 1:3500 ABINGTON AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-3547
Practice Address - Country:US
Practice Address - Phone:727-866-3831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist