Provider Demographics
NPI:1639506033
Name:HAYES, VICTORIA AUTUMN GOMBERT (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:AUTUMN GOMBERT
Last Name:HAYES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:921 S 8TH AVE STOP 8333
Mailing Address - Street 2:ISU COLLEGE OF PHARMACY
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-8333
Mailing Address - Country:US
Mailing Address - Phone:208-589-3784
Mailing Address - Fax:
Practice Address - Street 1:921 S 8TH AVE STOP 8333
Practice Address - Street 2:ISU COLLEGE OF PHARMACY
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-8333
Practice Address - Country:US
Practice Address - Phone:208-589-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist