Provider Demographics
NPI:1508019407
Name:BLACK, GWEN RENEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:RENEE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:GWEN
Other - Middle Name:RENEE
Other - Last Name:SHEELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7858 S UNIVERSITY WAY
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-3300
Mailing Address - Country:US
Mailing Address - Phone:720-488-4199
Mailing Address - Fax:
Practice Address - Street 1:2500 S HAVANA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1618
Practice Address - Country:US
Practice Address - Phone:303-388-4503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist