Provider Demographics
NPI:1689778094
Name:MARTIN, GWENDOLYN WADE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:WADE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 LAKEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35504-6788
Mailing Address - Country:US
Mailing Address - Phone:205-295-0068
Mailing Address - Fax:
Practice Address - Street 1:2405 US HIGHWAY 78
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501
Practice Address - Country:US
Practice Address - Phone:205-295-0068
Practice Address - Fax:205-221-2407
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist