Provider Demographics
NPI:1689725012
Name:GAUGHAN, KEVIN MARTIN (BS PHARMACY)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MARTIN
Last Name:GAUGHAN
Suffix:
Gender:M
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 RIPLEY RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-9280
Mailing Address - Country:US
Mailing Address - Phone:304-927-4477
Mailing Address - Fax:
Practice Address - Street 1:120 MCGRAW ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271-1111
Practice Address - Country:US
Practice Address - Phone:304-372-4487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5676183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist