Provider Demographics
NPI:1518560788
Name:GAUTHIER, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 SMITHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02896-7226
Mailing Address - Country:US
Mailing Address - Phone:401-765-6722
Mailing Address - Fax:401-769-2884
Practice Address - Street 1:595 SMITHFIELD RD
Practice Address - Street 2:
Practice Address - City:NORTH SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02896-7226
Practice Address - Country:US
Practice Address - Phone:401-765-6722
Practice Address - Fax:401-769-2884
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI03830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist